Strategic Plan

Malaria Control Program Pakistan

(2015-2020)

‘Strengthening
Strengthening m
malaria control interventions
s in high
and moderate endemic districts’

and

‘Moving
Moving towards eliminating malaria in low endemic
districts’

Prepared by:
Directorate of Malaria Control Supported by:
Pakistan World Health Organization
i
( May, 2014)

Strategic Plan

Malaria Control Program Pakistan

(2015-2020)

‘Strengthening malaria control interventions in high

and moderate endemic districts’

and

‘Moving towards eliminating malaria in low endemic

districts’

Prepared by:

Directorate of Malaria Control Pakistan

Supported by

World Health Organization

ii
List of Contributors:

Directorate of Malaria -Islamabad

1. Mr. Muhammad Aslam Khan – Director DOMC
2. Mr. Muhammad Mukhtar – Senior Scientific Officer
3. Dr. Muhammad Sulaiman Memon – Epidemiologist
4. Dr. Abdul Majeed – Senior Project Officer
5. Mr. Naveed Ahmed Chaudhry – Manager PSM
6. Dr. Saba Farooqi – Manager M&E
7. Dr. Irshad – Epidemiologist
8. Dr. Inamullah Kakar – Program Officer
9. Dr. Hameedullah – M&E Officer KPK/FATA
10. Dr. Bashir Jamali – M&E Officer Balochistan
11. Mr. Muhammad Usman Sherani – M&E Officer Balochistan

Department of Health/Directorate of Malaria (Provinces and Regions)

1. Dr. Nahid Jamali - Program Manager Sindh
2. Dr. Muhammad Faheem –Program Manager KPK
3. Dr Afifi – Director CDC Punjab
4. Dr. Abdul Razzaq – Additional Director Malaria Control Punjab
5. Dr. Kamalan Ghichki – Program Manager Balochistan
6. Dr. Qasim Abbas - Program Manager FATA

World Health Organization

1. Dr. Qutbuddin Kakar- National Professional Officer Islamabad
2. Dr Muhammad Zeeshan- National Program Officer KP/FATA
3. Dr Ali Raja - National Program Officer Punjab
4. Dr Sarmad Saeed Khan- National Program Officer Balochistan
5. Dr Shafi Kalhoro - National Program Officer Sindh

Save the Children

1. Dr. Muhammad Imran-Director Global Fund Programs
2. Mr. Ali Asghar-Manager MEAL GF R-10
3. Neelum Wasif-Grants Coordinator-GF R-10
4. Zia-ur-Rehman-Manager Finance-GF R-10
5. Dr. Maha Talat-Manager Training and Communication-GF R-10
6. Mr. Alamgeer Khan-Manager Logistics and Operations-GF R-10

Merlin
Mr. Naeem Durani- Program Manger

Pakistan Medical & Research Council

Dr. Muhammad Arif Munir- Principal Research Officer

Consultant:
Dr Nauman Safdar- National Consultant ‘Malaria Control Strategic Plan, Pakistan 2015-
2020’

iii
CONTENTS

FOREWORD......................................................................................................................... vii
ACRONYMS ........................................................................................................................ viii
A-CORE PLAN ....................................................................................................................... 1
1. BACKGROUND ................................................................................................................. 1
1.1. Geography, population and climate.............................................................................. 1
1.2. Political and economic situation ................................................................................... 2
1.3. Health Situation: .......................................................................................................... 3
1.3.1. Health infrastructure: Public sector ....................................................................... 3
1.3.2. Health infrastructure: Private sector ...................................................................... 3
1.4. Malaria Control Strategic Plan, Pakistan (2015-2020) .................................................. 5
1.4.1. National Malaria Strategic Plan 2011-2015 ........................................................... 6
1.4.2. International malaria review mission (MPR)-Federal and Provinces/Region ......... 6
1.4.3. Malaria indicator survey (MIS) .............................................................................. 7
1.4.4. National, provincial/regional and community events .............................................. 7
2. SITUATION ANALYSIS ...................................................................................................... 9
2.1. Malaria burden and epidemiology ................................................................................ 9
2.1.1. Country situation ................................................................................................... 9
2.1.2. Impact on malaria incidence (2009-2013) ............................................................12
2.1.3. Stratification of endemicity ...................................................................................15
2.2. Malaria case management ..........................................................................................18
2.2.1. Diagnostic arrangements .....................................................................................18
2.2.2. Treatment arrangements .....................................................................................20
2.3. Malaria prevention ......................................................................................................21
2.3.1. Long lasting insecticide treated nets (LLINs) ........................................................21
2.3.2. Indoor residual spraying (IRS) .............................................................................23
2.3.3. Larvicidal .............................................................................................................24
2.4. Behaviour change communication ..............................................................................24
2.5. Technical & managerial capacity in planning, implementation, management of malaria
control interventions ..............................................................................................................27
2.5.1. Program management .........................................................................................27
2.5.2. Program funding ..................................................................................................28
2.6. Quality assured strategic information (epidemiological, entomological and operational)
30
2.7. Malaria treatment and prevention services in humanitarian crises, emergencies and
cross boarder ........................................................................................................................31
3. SWOT ANALYSIS .............................................................................................................33
3.1. Malaria case management and treatment ...................................................................33
3.2. Malaria prevention (LLINs, IRS and Larvicidal) ...........................................................34
3.3. BCC, IEC and advocacy .............................................................................................34
3.4. Programme Management ...........................................................................................35
3.5. Surveillance and monitoring and evaluation ................................................................35
3.6. Procurement and supply management........................................................................35
3.7. Epidemiology and entomological data .........................................................................36
3.8. Epidemic preparedness & response and Cross border situation .................................36
4. GAP ANALYSIS ................................................................................................................37
4.1. Inadequate malaria diagnostic service network ...........................................................37
4.2. Treatment services not as per the protocols................................................................38
4.3. Quality assurance arrangement sub-optimal ...............................................................38
4.4. Universal coverage of LLINs not achieved ..................................................................38
iv
 4.5. IRS coverage is low in high malaria prevalent UCs: ....................................................39
4.6. Larvicidal not implemented effectively .........................................................................40
4.7. Community mobilization not effective ..........................................................................40
4.8. Funding mainly depending on external support ...........................................................40
4.9. Program management ................................................................................................40
4.10. Malaria control problems are not addressed through operational research ..............41
4.11. Storage capacity for drugs and supplies not as per standards .................................41
4.12. Significant issues in training in malaria control ........................................................41
4.13. Epidemiological and entomological information inadequate .....................................42
4.14. Weak system for malaria control services in humanitarian crises, emergencies and
cross border situation ............................................................................................................42
5. MALARIA CONTROL PROGRAM PAKISTAN: VISION, GOAL AND OBJECTIVES .........44
5.1. Vision ..........................................................................................................................45
5.2. Goal ............................................................................................................................45
5.3. Objectives ...................................................................................................................45
5.4. Outcome Indicators .....................................................................................................46
5.5. Impact Indictors ..........................................................................................................46
5.6. Target .........................................................................................................................46
5.7. Strategic approach and interventions ..........................................................................46
6. STRATEGIES, INTERVENTIONS AND LIST OF ACTIVITIES ..........................................51
6.1. Sustain and expand quality assured diagnosis of all suspected malaria cases in high,
moderate and low risk districts ..............................................................................................51
6.2. Strengthen anti-malarial supply at the district/agency level and improve treatment
practices ...............................................................................................................................54
6.3. Strengthen quality assurance system for diagnostic services at national,
provincial/regional and at district level ...................................................................................55
6.4. Universal coverage with LLINs in 66 districts with API/SPR > 5 (mass distribution) and
in foci and emergencies in 57 districts with API between 1-5 and API <1 ..............................56
6.5. Implement IRs in 66 high risk districts with API/SPR >5 (15% Household) and selective
spraying in foci and emergency supplies of IRS for 57 moderate and low risk districts ..........58
6.6. Implement LSM targeted to eliminate malaria foci in districts and to support urban
malaria control & elimination, and general nuisance mosquito control. ..................................59
6.7. Comprehensive implementation of BCC interventions in all 66 high risk districts ........60
6.8. Increase public sector funding for malaria control interventions ..................................69
6.9. Strengthen national and provincial/regional and district set-up with technical and
administrative human resource .............................................................................................70
6.10. Operational research to inform policy and decision making .....................................71
6.11. Procurement and good storage practices at national and provincial/regional and
district for anti-malarial drugs, LLINs and IRS .......................................................................72
6.12. Establish core of master trainers at provincial/regional level ....................................72
6.13. Standardized recording and reporting system for malaria case management and
prevention and entomological information .............................................................................73
6.14. Capacity at provincial/regional and district level to address malaria control and
prevention in humanitarian crises, emergencies and cross-border situation ..........................74
B-BUDGET SUMMARY ........................................................................................................76
C- M&E FRAMEWORK .........................................................................................................78

LIST OF TABLES AND FIGURES

Table 1: Number of major public sector health facilities in provinces/region ............................... 3

v
Table 2: Private health care providers by country/province4 2009-10 ......................................... 4
Table 3: Out-patient service providers 2009-10 by type and province3 ....................................... 4
Table 4: Malaria Data – MIS Pakistan 2013 ..............................................................................11
Table 5: Malaria caseload (Confirmed and Clinical) DHIS 2013 ................................................12
Table 6: Stratification of districts and agencies .........................................................................16
Table 7: Province/Region wise strengthened MC and RDT centers through GF support (2012-
13) ............................................................................................................................................18
Table 8: List of human resource trained in MC and RDT in 38 high risk districts/agencies (2012-
13). ...........................................................................................................................................19
Table 9: Private sector case notification (9 pilot districts/agencies 2013) ..................................19
Table 10: List of human resource trained in treatment in 38 high risk districts (2012-13)..........20
Table 11: LLINs distributed (2012-13) .......................................................................................21
Table 12: Trainings on LLINs distribution strategy GF supported (2013) ...................................22
Table 13: Province/district wise coverage of IRS (Household covered in 2012-13) ...................23
Table 14: List of IRS equipment in provinces/regions supported by GF (2013) .........................24
Table 15: Advocacy, BCC activities and Beneficiaries Reached ...............................................25
Table 16: Federal DoMC development budget from 2001-2013 ................................................29
Table 17: Trainings on MIS (2012-13) .......................................................................................31
Table 18: Strategic approach ....................................................................................................47
Table 19: Malaria program intervention outline..........................................................................48
Table 20: API projection 2015-2020 ..........................................................................................51
Table 21: RDTs required (2015-2020).......................................................................................52
Table 22: Private sector involvement (2015-2016) ....................................................................53
Table 23: LLINs requirements for universal coverage (2015-2020) ...........................................56
Table 24: Households to be covered through IRS (2015-17) .....................................................58
Table 25: Advocacy with CBO, NGO s and LHWs ....................................................................61
Table 26: Community awareness sessions at facility level 2015-2020 ......................................62
Table 27: Community awareness session CBOs/NGOs (2015-2020 .........................................62
Table 28: BCC by facility staff (2015-2020) ..............................................................................63
Table 29: BCC- Street Theater..................................................................................................65
Table 30: World Malaria day events (2015-2020) ......................................................................65
Table 31: BCC- Branding of facilities.........................................................................................66
Table 32: BCC- Broadcast radio message (2015-2020) ............................................................67

Figure 1: District wise malaria endemicity in 2012 .....................................................................10

Figure 2: Malaria epidemiological trend (2000-2013) ................................................................11
Figure 3: Malaria incidence trend (2009-2013) in 19 high risk districts of Pakistan ....................13
Figure 4: PV: PF ratio (2009-2013) in 19 GF district ..................................................................14
Figure 5: Impact on P.falciparum incidence in R-7 district .........................................................14

vi
FOREWORD

In recent years, there has been significant progress in expanding coverage of key malaria
interventions such as early diagnosis and prompt treatment with effective anti-malarial drugs
and vector control interventions with an ambition to provide universal coverage with Long
Lasting Impregnated Nets (LLINs) in affected populations in Pakistan. Major efforts to scale up
have had the support of international and national partners. In 2012/13 radical treatment has
been first introduced at primary and secondary health facilities, microscopic diagnosis was
strengthened and there was an expansion of the use of Rapid Diagnostic Tests which diagnose
both P.vivax and P.falciparum at both hospital and health facility levels. Vector control was
stepped up and only in 2012/13 about 1.6 million LLINs were distributed free of cost in
malarious areas.

The main aim of expanding access to these interventions was to achieve objectives set out in
previous national plans and to address the recommendations of national and international
reviews. Since 2012 the malaria control activities in districts in high risk stratum have increased
rapidly resulting in increased coverage with LLINs, and availability of ACTs in public health
facilities. The results to date is due to the enormous support of implementing partners delivering
health services on the ground, donors and technical support agencies.

Estimates based on the latest surveys in country and distribution databases indicate that we are
making steady progressing in achieving Scale-Up for Impact. Focus in the previous National
Strategic Plan was aimed at increasing availability of interventions at health facility level. This
new strategic plan emphasizes the need to create and impact by comprehensive coverage and
sustainability of all interventions by involving all the stakeholders including key affected
communities.

Mr. Mohammad Aslam Khan

Director, Malaria Control Programme
Ministry of Health
Government of Pakistan

vii
ACRONYMS
ACT Artemisinin-based Combination Therapy
ANC Antenatal Care
API Annual Parasite Index
BCC Behavior Change Communication
CQ Chloroquine
EPI Extended Program of Immunization
FATA Federally Administered Tribal Areas
FM Facility Monthly Report
GFATM Global Fund to Fight AIDS, Tuberculosis & Malaria
GPIRM Global Plan for Insecticide Resistance Management
DEWS Disease Early Warning System
DHIS District Health Information System
DOT Directly Observed Treatment
DOMC Directorate of Malaria Control
IEC Information, Education and Communication
IMNCI Integrated Management of Newborn Childhood Illness
IRS Indoor Residual Spraying
IVM Integrated Vector Management
KPK Khyber Pukhutoon Khwa
LLINs Long Lasting Insecticidal Net
LSM Larvicidal Source Management
MC Microscopy
MCP Malaria Control Program
M&E Monitoring and Evaluation
MIS Malaria Information System
MIS Malaria Indictor Survey
MoH Ministry of Health
NGOs Non Governmental Organizations
PF Plasmodium falciparum
PV Plasmodium vivax
RBM Roll Back Malaria
RDT Rapid Diagnostic Test
SP Sulphadoxine-Pyrimethamine
SPR Slide positivity rate
TGF The Global Fund
UCs Union Councils
VBD Vector Born Disease
WHO World Health Organization
WHOPES WHO Pesticide Evaluation Scheme

viii
 A-CORE PLAN
1. BACKGROUND
1.1. Geography, population and climate

Pakistan belongs to the South Asian region and covers an area of about 796,096 sq. kilometers.
It is bordered by Afghanistan to the north-west and Iran to the west while the People's Republic
of China borders the country in the north and India to the east. Pakistan has five provinces;
Balochistan, Gilgit-Baltistan (GB), Khyber Pakhtunkhwa (KP), Punjab, Sindh, and three regions;
Azad Jammu Kashmir (AJK), Federally Administered Tribal Areas (FATA) and Islamabad
Capital Territory (ICT). Pakistan is divided into three major geographic areas: the northern
highlands, the Indus River plain and the Balochistan Plateau. The northern highlands contain
some of the world's highest peaks. The Balochistan Plateau lies in the west and the Thar Desert
in the east. The 1,609 km (1,000 mi) Indus River and its tributaries flow through the country from
the Kashmir region to the Arabian Sea. There is an expanse of alluvial plains along it in Punjab
and Sindh.

The last population census was done in 1998. Currently the country population1 is estimated at
182.5 million with 35% urban and 65% rural. The population growth rate is projected at 1.7
annually2. The highest population density is in Punjab province and lowest in Balochistan
province. The population less than 5 years is 12.5%, between 0-14 is 37%, 15-64 is 59% and
above 65 years is 4% whereas, and there are 1.07 male / female in the country. The national
language of the country is Urdu whereas the official language is English.

The climate varies from tropical to temperate, with arid conditions in the coastal south. There is
a monsoon season with frequent flooding due to heavy rainfall and a dry season with
significantly less rainfall or none at all. There are four distinct seasons: a cool, dry winter from
December through February; a hot, dry spring from March through May; the summer rainy
season, or southwest monsoon period, from June through September; and the retreating
monsoon period of October and November. Rainfall varies greatly from year to year, and
patterns of alternate flooding and drought are common.

1
National Institute of Population Studies, Government of Pakistan, 2012
2
data.world bank.org/indicator/SP.pop.grow, 2009-2013
1
In past few years, Pakistan has faced several natural disasters including earthquakes (KP and
Balochistan) and flooding in several districts across the country (almost every year) and is prone
to such natural disasters in future.

1.2. Political and economic situation

The Islamic Republic of Pakistan has a parliamentary system of government. The President of
Pakistan is the head of state, the Prime Minister is head of government, and there is a multi-
party system. The Government of Pakistan vide 18th constitutional amendment devolved
multiple functions, including federal units of health programs, to the provinces with effect from
1st July 2011. However, recognizing the importance of several health functions, including the
management of a few key public health programs, a Federal Ministry of National Health
Services, Regulations & Coordination (NHS, R&C) has been established in Islamabad; the
Directorate of Malaria Control (DoMC) is being managed by this Ministry.

According to the World Bank categorization, Pakistan falls in the list of lower-middle-income
countries, has primarily an agrarian economy (66% population lives in the rural area), and has
diverse cultural and geographical patterns. Health cannot be segregated from the country’s
overall economic and social development. Pakistan’s Human Development Index (0.515) ranks
low 146 out of 187 countries and its GDP per capita is estimated as 2,566 US$. Life expectancy
and education are also low; 0.487, 0.217.3. The annual per capita health expenditures for
Pakistan as per National Health Accounts (NHA) 2009-10 are (Rs.2,611) 31.2 US$4. For
comparison, the respective figures reported to WHO by India and Bangladesh are 51.0 US$ and
25.0 US$, respectively. According to the NHA, the ratios of health expenditures over GDP
(2009-10) are 3.0% while this ratio for public and private sector health expenditures is 9.2% and
2.5% respectively. In the health sector, Pakistan is receiving major international grants from the
Global Initiative for Vaccination and Immunization (GAVI), the Global Fund to Fight against
AIDS, TB and Malaria (GFATM) and USAID. According to the HDI, 60.3% of Pakistan's
population lives on under $2 a day and some 21% live on under $1 a day.

3
United Nations Development Program, HDI report 2013
4
National Health Accounts 2009-2010, Pakistan Bureau of Statistics, Government of Pakistan
2
1.3. Health Situation:
In Pakistan the distribution of years lost by causes is mainly due to communicable diseases
(64%)5 followed by non-communicable disease (26%) and injuries (9%). The under-5 mortality
rate (per 1000 live births) is 72, whereas the maternal mortality ratio (per 100,000 live births) is
260 in 2011.

1.3.1. Health infrastructure: Public sector

The public sector is the main source for the provision of preventive care and hospital care to the
urban and rural populations. In the provision of curative care for minor ailments, the public
sector caters services to around 25% of the population. Health services in the public sector are
provided by various types of general and specialized hospitals. There is also a network of
primary health care outlets including Rural Health Centers (RHCs), Basic Health Units (BHUs),
dispensaries and Maternity and Child Health (MCH) centers and about hundred thousand lady
health workers (LHWs). These centers are mainly under the control of the provincial
departments of health and at the level of district is management by EDO/DHO.

Table 1: Number of major public sector health facilities in provinces/region

Districts/ region Number of Facilities

Hospital RHC BHU Dispensaries MCH Center

KP 103 85 819 360 58
Balochistan 93 69 499 545 93
Sindh 81 125 707 272 36
FATA 32 8 173 428 75
Punjab 124 299 2471 181 166
TOTAL 433 586 4669 1786 428

The capacity of the district health authorities is generally considered suboptimal and this is one
of the main reasons for unsatisfactory progress in health care delivery and indicators.

1.3.2. Health infrastructure: Private sector

The private sector is large and unregulated comprising both qualified and unqualified service
providers in the disciplines of Allopathy, Homeopathy and tibb (Traditional Herbal Medicine).
The private sector caters to about 75% of the population’s curative primary healthcare needs.

5
Pakistan health profile, WHO, 2013
3
 The not-for profit NGOs range from small-scale local setups to a countrywide network of health
outlets such as PRSP/PPHI (managing about 4,000 primary health care facilities in the country).
Table 2: Private health care providers by country/province4 2009-10
Country/province Urban Rural Total
Number % Number % Number %
Pakistan 83,689 40 123,023 60 206,712 100
Punjab 47,005 36 83,406 64 130,411 63
Sindh 23,642 71 9,637 29 33,279 18
KP 11,047 29 27,052 71 38,099 18
Balochistan 1,995 41 2,928 59 4,923 2

The distribution of private health care providers varies among the provinces. Punjab, being the
most populous province, leads with 63% of the total private sector health care providers. Sindh
has the highest percentage of urban health care providers (71%) followed by Balochistan (41%).
With respect to rural health care providers, KP has the highest percentage (71%) followed by
Punjab (64%), Balochistan (59%) and Sindh (29%).
Malaria is mainly considered as a rural disease, so involving private care providers in the rural
areas should be the priority.

Table 3: Out-patient service providers 2009-10 by type and province3

Country/ province

Hakeem/Herbalist

Traditional birth
Individually run

Dental clinics

Homeopathic

attendant/Dai
solo clinics

Out-patient
centers

Others
clinic

clinic

Number Total
Pakistan 96,645 916 6,443 27,819 28,985 29,445 6,590 196,843
Punjab 47,749 541 3,865 22,584 23,402 21,264 5,766 125,171
Sindh 19,548 99 1,214 2,241 3,062 4,169 409 30,742
KP 26,222 258 1,230 2,830 2,2225 3,049 391 36,205
Balochistan 3,126 18 134 164 296 963 24 4,725

For all of Pakistan, the estimated total number of out-patient health service providers is
196,843; of these, individually run solo clinics (Allopathic clinics) have the highest proportion
(49%) followed by Traditional Birth Attendant/ Dai (15%), Hakeem/Herbalist clinics (14.7%),

4
Homeopathic clinics (14%), Dental clinics (3.3%) and others (3.3%). In addition, anecdotal
information suggests that there are three times more unqualified than qualified providers in
Pakistan. The Malaria Indictor Survey 2013 showed that people mostly use allopathic medicines
for the treatment of fever.
This implies that while considering the involvement of the private sector in malaria case
management the priority should be given to the clinics run by qualified allopathic doctors.

1.4. Malaria Control Strategic Plan, Pakistan (2015-2020)

After 18 constitutional amendment in 2011, health became the sole provincial prerogative
making respective departments of health responsible for institutional directions, strategies and
resource allocation. The new plan is meant to incorporate; changes in country context due to
post devolution scenario; experiences of provinces, regional and district of implementing
interventions; ownership by all stakeholders with lead role of provinces and regions; change in
strategies related to LLINs and IRS implementation; and making projections and estimating
costs to bring an impact on disease by reducing malaria cases.

Malaria Control Strategic Plan (2015-2020), Pakistan is a “full expression of demand” and is a
tool mainly to give insight towards Malaria program, sensitizing policy makers and partners and
basis to generate resources. The plan is guided through key resources which are National
Malaria Strategic Plan (2011-2015), Rapid programmatic assessment 2013, Malaria program
review-MPR 2013, Malaria indicator survey-MIS 2013 and Provincial and Regional malaria
control strategic plans 2014.

Malaria control strategic plan 2015-2020, Pakistan entails developing innovative strategies that
will:
a. Improve the performance and impact of malaria control in Pakistan with maximizing
public sector investment and accountability in malaria control activities
b. Reduce diagnostic delay related to malaria and improve the efficacy of treatment
c. Prevent malaria disease by effective vector control interventions with universal
coverage of LLINs and selective IRS
d. Better surveillance and program management
e. Prioritize research that has the potential to change policy and practice in malaria
care in the province

5
1.4.1. National Malaria Strategic Plan 2011-2015
The National Strategic Plan (NSP) 2011-15 provides a detailed account on the status and
direction of the major malaria prevention and control strategies that include quality case
management through prompt diagnosis and effective treatment, selective vector control, scaling
up of the use of long-lasting insecticide treated nets and epidemic preparedness, detection and
response. The strategy contains initiatives to improve community level case-management and
control. It provides supporting strategies that include partnership and coordination, monitoring
and evaluation, operational research, and human resources development which will contribute
to health system strengthening. The strategy was focussed on reducing malaria in 38 districts
identified as high-risk areas, where the greatest gains will be made in reducing overall national
malaria burden and the highest cost-effectiveness can be achieved. This will contribute to
achieving the Millennium Development Goals. In addition to the focus on these priority districts,
the strategy aimed to sustain existing successes and maintain the low endemicity in formerly
endemic areas (for example, in Punjab Province). The overall goal was in line with MDG 6 and
aimed to reduce the burden of malaria by 75% percent (from 2000 levels) by 2015. The
objectives were to provide the basis for achieving universal coverage of malaria control
interventions to the most at-risk populations in highly endemic districts by 2015 by; enhancing
access by the population at risk to quality assured early diagnosis and prompt, effective
treatment services; scale-up coverage of multiple prevention interventions (especially LLINS &
Indoor Residual Spraying [IRS]) to the level of universal coverage in the target population in
high-risk districts; strengthen existing Malaria Control Programme management capacity to
coordinate, plan, implement and monitor effective curative and preventive interventions
nationwide; strengthen programme capacity in enhanced epidemiological surveillance for timely
detection and curtailment of malaria outbreaks; and improve public sector health facility
utilization for early diagnosis, effective treatment and preventive measures through enhanced
community awareness and participation.

In the situation analysis section below, the key implementation achievements by the program
since the last strategic plan 2011-2015 has been described.

1.4.2. International malaria review mission (MPR)-Federal and Provinces/Region

In year 2013, with the support from WHO, a detail malaria program review was conducted in all
the provinces, FATA region of Pakistan and at federal level. The exercise was based on detail
desk review and provided in-depth information of the malaria control situation and highlighted

6
some the key areas which requires strengthening in order to have an effective malaria control
program in the country. The following thematic areas were discussed.
• Program Management
• Malaria Diagnosis and Case Management
• Malaria Vector Control
• Malaria Commodities, Procurement and Supply Chain management
• Advocacy, Information, Education, Communication and Community Mobilization
• Epidemiology, Surveillance, Monitoring, Evaluation and Operational Research
• Epidemic and Emergency Preparedness and Response

Note: The findings of the MRP has been used in respective provincial and regional strategic
plans and also in various sections of the Malaria Control Strategic Plan Pakistan

1.4.3. Malaria indicator survey (MIS)

A malaria indicator survey has been conducted in month of Sept-Nov, 2013 in 38 malaria high
risk districts in the country which included three provinces (Sindh, Balochistan and KP) and all
the agencies of FATA region. The survey included a Household Survey and a Health Facilities
Survey and the findings of the survey were very informative and are used under the relevant
sections of provincial and regional strategic plans and also in Malaria Control Strategic Plan
Pakistan.

1.4.4. National, provincial/regional and community events

The Strategic Plan was developed through a broad based consultative process which involved
national, provincial and regional consultations. The following were the key events:
1. National consultative meeting Bhurban (participated by Federal, Provincial and
Regional Malaria control programs, WHO, consultants and partners)
2. Provincial consultative meetings (participated by DoH, WHO, consultants and
partners)
3. National consultative meeting Islamabad (participated by Federal and Provincial and
Regional Malaria control programs, DoH, WHO, consultants and partners)

District and community involvement in development process

In province of Balochistan, district Pishin and district Killa Abdullah was visited which are
malaria high risk districts. Interactions were made with the EDO(H), Medical Superintendent of

7
DHQ hospital, PPHI representative, Distt. health management team and partners. Moreover,
rural health centers and basic health units were visited where facility in charges and malaria
patients were interviewed to get their feedback on the strategies and interventions. Household
where LLINs were distributed and IRS was sprayed were also visited. Community stakeholders
were also consulted during these visits to understand their perspective to the strategies and
interventions.

At Quetta, which is the provincial capital, meeting with Minister Health, Secretary Health, Dean
Institute of Public Health, Provincial Coordinator Malaria Control program, Provincial LHW
program, PPHI representatives, SRs, SSRs, Save the Children, WHO, Bill and Malinda Gates
foundation were carried out on the proposed malaria control strategies and interventions.

Note: The list of events related to development of national and provincial/ regional level along
with dates and participants has been annexed.

8
2. SITUATION ANALYSIS
2.1. Malaria burden and epidemiology

2.1.1. Country situation

With an estimated burden of 1.6 million cases annually, malaria is considered as a major public
health problem in Pakistan. It contributes 22% of total disease burden in the Eastern
Mediterranean Region (EMR) and has been grouped with Sudan and Yemen in category 3
countries6 . Epidemiologically, Pakistan is classified as a moderate malaria endemic country
with national API averaging at 1.69 and important diversity within and between the provinces
and districts. The two parasites which account for malaria in Pakistan are Plasmodium Vivax
and Falcipaum. The main vectors in the country are Anopheles Culicifacies and Anopheles
Stephensi.

Among the key underlying risk factors for malaria endemicity in Pakistan includes; mass
population movements within the country and across international borders with Iran and
Afghanistan, natural disasters and civil unrest, unpredictable transmission patterns due to
climatic changes, low immune status of the population and poor socioeconomic conditions.
These are accentuated by the declining health infrastructure, resource constraints, poor access
to preventive and curative services and lack of monitoring drug resistance in parasites and
insecticide resistance in vectors. There are various constraints and inequalities posed by the
unstable political and security situation in some districts which undermine both universal access
as well as quality assurance of the malaria control program in Pakistan. In addition, gender
remains one of the key factors affecting access to healthcare in the country.

The first ever malaria prevalence survey was conducted in 2009 in 19 highly endemic districts of
the country showing highest prevalence rates in FATA 13.9% followed by Balochistan 6.2% and
Khyber Pakhtunkhwa 3.8%. It was more or less consistent with the reported incidence. In the
recent most Malaria Indicator Survey 2013 conducted in 38 highly endemic districts, revealed
that overall malaria prevalence was 1.59% (15.9/1000 population), PV:PF ratio was 84:16. The
prevalence was highest in FATA followed by KPK, Balochistan and Sindh.

The demographic information of microscopically confirmed malaria cases is limited. Situation

analysis conducted in the low endemic province of Punjab in 2008 revealed that males of age >

6
World Malaria Report, 2013
9
14 were more affected by malaria infections compared to females of the same age group
indicating the low immunity linked with low endemicity and the relatively higher exposure
potential of males to vector bites during their late-evening agriculture activities. In the 19 priority
districts the % of confirmed malaria cases among children below 5 years was 17.82 % of
confirmed cases.

The mapping of Malaria situation (2012 data) shows clearly that the highly endemic districts are
located gradually in Balochistan (API 7.68), FATA (6.83), Sindh (2.92), and KPK (2.76), Punjab
(0.19) and AJK (0.10). Many reported cases from these provinces/region are due to falciparum
malaria which is the most dangerous form of malaria. Malaria is typically unstable (seasonal),
with peaks around September for vivax malaria and around October for falciparum malaria.
Proportion of P falciparum also varies widely with a range of 2.5% - 44.3% respectively. The
figure below shows the country wide malaria endemicity during 2012.

Figure 1: District wise malaria endemicity in 2012

Source: WHO report, 2012.

In 2013, 281,755 confirmed malaria cases were reported through national malaria disease
surveillance system. However, during the same period 3.1 million cases were clinically
diagnosed and treated at public sector outpatient facilities (DHIS-2013), whereas 244 death are
due to malaria were also reported in DHIS 2013. The number of reported malaria cases almost
doubled from 2009 to 2012 with an equivalent rise in API. Similar trends were observed in low
10
 transmission areas of Punjab mainly due to the recurring floods in 2010 & 2011. In Pakistan and
almost all age groups are at risk of acquiring infection. However, the Government of Pakistan
recognizes children below age 5 years and pregnant women as high-risk population groups.
The figure below presents the epidemiological trends based on malaria indicators since 2000-
2013.

Figure 2: Malaria epidemiological trend (2000-2013)

8
7
6
5
4 SPR/TPR
3 API
2 BER
1
0

Source: DoMC Islamabad,2013

The reported blood examination rate is quite low 2.87, whereas there is was a low API in initial
years but has increased since 2010.

The table below shows the MIS data reported from four provinces and FATA region during
2013.

Table 4: Malaria Data – MIS Pakistan 2013

Province Population TOTAL Indicators
Slides/RDT Positive P.V PF Mix TPR API % P.F
Punjab 93579797 1668817 9295 8585 680 30 0.56 0.10 7.64
Sindh 42922727 1275543 70269 51094 14273 4902 5.51 1.64 27.29
KPK 23295610 698176 98137 90606 5438 2093 14.06 4.21 7.67
FATA 232083 34116 26614 6071 1431 14.70 8.82 21.99
3,869,841
Balochistan 9761994 546418 69678 46504 19602 3572 12.75 7.14 33.26
AJK 4261129 140788 257 3 0 0.18 0.06 1.15
260
TOTAL 177691098 4561825 281,755 223660 46067 12028 6.18 1.59 20.62
Source: Reported by DoMC Islamabad, MIS 2013

11
 There is a marked variation in API by province/regions. In 2013, there is very high API observed
in most of the provinces/region i.e. > 8 in FATA, > 7 in Balochistan and >4 in KP. In 2012, the
picture was almost similar where most of the districts with high malaria endemicity belongs to
FATA, Balochistan, KP and Sindh province. However, in south of province of Punjab a
moderate zone of malaria endemicity was also observed.

The table below shows the DHIS data related to confirmed and clinical malaria cases in 2013.

Table 5: Malaria caseload (Confirmed and Clinical) DHIS 2013

Province Clinical cases Suspected/Tested Confirmed P.Falciparum Indoor cases Deaths
cases cases
PHC SHC PHC SHC PHC SHC PHC SHC PHC SHC PHC SHC
Punjab 637,724 154,548 563871 405595 5,796 5,877 408 534 5530 25217 0 131

Sindh 1490723 306610 350564 253823 56675 16490 7259 2978 2490 7296 0 60
KPK 219,409 133970 88290 162,869 13526 21689 1258 1983 754 4268 49 4
FATA 63922 36539 - - 3228 13573 684 1407 - - - -
Balochistan 133953 13574 22714 18047 3390 1699 1223 777 165 293 - -
TOTAL 2545731 645241 1025439 840334 82615 59328 10832 7679 8939 37074 49 195

There is wide variation between the malaria confirmed cases reported in MIS 281,755 and DHIS
141,943. Moreover, still a very high number of clinical malaria cases 3,190,972 have been
reported in DHIS during 2013. The mortality reported in DHIS due to malaria was 244.

2.1.2. Impact on malaria incidence (2009-2013)

The routine data from the 19 districts from GF R-7 which initiated programme interventions in
2009 has shows an increase in API in the initial years followed by gradual reduction in malaria
incidence.

12
Figure 3: Malaria incidence trend (2009-2013) in 19 high risk districts of Pakistan

Malaria Incidence in R-7 Districts

12

10

0
2009 2010 2011 2012 2013
API

The figure above shows that in 2008-09 the overall malaria in these districts was 7.13
cases/1000 population with predominantly P vivax. In the initial years there was an increase in
API observed (10.8/1000) mainly due to improved surveillance after establishment of new
malaria microscopy centres at RHCs and hospitals RDT centers at BHUs and putting
standardized recording and reporting tools. With the introduction of comprehensive control
interventions including vector control i.e. 15% highly endemic population got 2 rounds of IRS
and 30% rural population was covered with LLINs, malaria levels came to 8.5, 8.7 respectively
in 2012 and 2013.

In initial years of GF R-7 implementation the diagnosis and treatment of P.Vivax at the
peripheral level was a challenge due to absence of RDTs which helps diagnosing P.Vivax and
primaquine for radical treatment which were later introduced in 2013. The figure below shoes
that there has been a reduction in P.falciparumincidence and increase in P.vivax observed in
last few years with a change in the PV:PF proportion. The proportion has almost reversed in the
recent years compared to that in 2009 when the percentage of P.falciparum was very high, up
to 60%. Currently the proportion of PV to PF is 72:28, in these districts.

13
Figure 4: PV: PF ratio (2009-2013) in 19 GF district
80

70

60

50

40

30

20

10

0
2009 2010 2011 2012 2013
PV (%) Pf (%)

Since most of programmatic efforts were focused on reduction in P.falciparum thus Impact on
morbidity due to P.falciparum is more marked as compared to P.vivax, as shown in the figure
below.

Figure 5: Impact on P.falciparum incidence in R-7 district

0
2009 2010 2011 2012 2013
AFI

14
In 2009, P.falciparum incidence was 4.55 cases/1000 population which increased to 6.1 cases
per 1000 population when case detection improved due to full coverage of surveillance. The
analysis of 2013 malaria incidence data suggests that there has been 59% reduction in
P.falciparum morbidity since 2011, AFI dropped from 6.1 to 2.45 cases per 1000 population.
This reduction is planned to be further sustained by rolling the coverage of proven effective
interventions to >80% of the high risk districts population in phase-2 of the grant.

The 2013 malaria indicator survey further confirms this reduction in falciparum and suggests
that P.falciparum in some districts has gone below 10% of the district case load. The survey
showed that the prevalence was highest in FATA (27.5/1000 population) among the provinces
surveyed. Highest falciparum prevalence was found in FATA (4.5/1000 population). The survey
also showed that out of total 113 Union Councils surveyed, 35 UCs in FATA were served. 4
UCs showed positivity rate of less than 1 percent, whereas 13 had SPR between 1-5% and 6
UCs had the SPR more than 5% (hot spot), out of which four are from North Waziristan. In the
remaining 12 Union Councils the slide positivity rate was zero.

2.1.3. Stratification of endemicity

The districts and agencies in four provinces of Pakistan and FATA region were stratified based
on the API index from last three years average i.e. 2011-13. For the stratum 1, SPR >5 was
also considered to demonstrate the future change in stratification of districts based on
interventions.
The API > 5 and its other ranges have been taken to stratify the districts to show there malaria
transmission potential thus a way to structure the strategic approaches and interventions and to
demonstrate the impact of future investments. However, there will be possibilities in future which
may result in selecting the districts by order of priority and developing sub-stratums for priority
interventions. The priority many be given to those districts which have been highlighted in
recent malaria program review reports as high endemic districts with very high API>10, findings
of malaria indicator survey which shows an in-depth coverage level of interventions and their
impact up to the level of UC which is the smallest administrative unit, attaining more than 80%
coverage by case management and vector control in districts with on-going interventions by
public sector and donor agencies.

15
Table 6: Stratification of districts and agencies

Stratum-I (High Transmission) Stratum-II(Moderate Transmission) Stratum-III(Low Transmission)

District/Agency: API/SPR >5 District: API between 1-5 District: API<1
Province/Region API/SPR Province API Province API
FATA Sindh Sindh
1. FR Bannu/Laki 117.96 1. Benazirabad 3.14 1. Jamshoro 0.83
2. N. Waziristan 25.09 2. Shikarpur 2.83 2. Hyderabad 0.62
3. FR D.I.Khan / 13.27 3. Matiari 1.87 3. Karachi 0.15
Tank Punjab
4. Kurram 11.34 4. Kashmore 1.71 4. Bhakkar 0.72
5. Khyber 10.77 5. Ghotki 1.63 5. Rajanpur 0.51
6. FR Peshawar / 10.47 6. Jacobabad 1.57 6. Layyah 0.51
Kohat
7. Bajor 6.35 7. Sanghar 1.44 7. Nankana 0.26
Sahib
8. Mohmand 15.01 8. Dadu 1.35 8. Khushab 0.25
Punjab 9. Bahawalnagar 0.24
9. Orakzai 6.27 9. Muzaffargarh 1.56 10. Lodhran 0.23
Balochistan 11. Sheikhupura 0.23
10. S. Waziristan 5.68 10. Kalat 1.39 12. Mianwali 0.14
Sindh 13. Sargodha 0.11
11. Mithi/Tharparker 11.77 14. Hafizabad 0.11
12. Khairpur 9.78 15. Kasur 0.09
13. Umerkot 7.7 16. Chakwal 0.08
14. Thatta 5.21 17. Bahawalpur 0.08
15. Mirpurkhas 11.36 18. Mandi 0.07
Bahauddin
16. T.M.Khan 8.17 19. Sahiwal 0.06
17. Sukkur 7.57 20. Jhelum 0.05
18. Larkana 6.32 21. Jhang 0.05
19. T.Allahyar 6.29 22. Rahimyar 0.05
Khan
20. Kamber 5.46 23. Chiniot 0.04
21. Badin 5.29 24. Attock 0.04
22. N.Feroz 5.02 25. Okara 0.04
Balochistan 26. Sialkot 0.04
23. Zhoab 27.21 27. Vehari 0.04
24. Gawadar 25.83 28. Faisalabad 0.03
25. Kharan 20.92 29. Pakpattan 0.02
26. Bolan / Kachi 18.65 30. Khanewal 0.02
27. Kech 17.63 31. Gujrat 0.02
28. Nasirabad 15.71 32. Multan 0.02
29. Sibi 13 33. Rawalpindi 0.02
30. Jaffarabad 12.59 34. T-T-Singh 0.01
31. Harnai 11.7 35. Gujranwala 0.01
32. Dera Bugti 11.66 36. Lahore 0.01

16
Stratum-I (High Transmission) Stratum-II(Moderate Transmission) Stratum-III(Low Transmission)
District/Agency: API/SPR >5 District: API between 1-5 District: API<1
33. Loralai 10.37 37. Narowal 0
KP
34. Noushki 10.27 38. Malakand 0.68
35. Jalmagsi 9.51 39. Peshawer 0.57
36. Awaran 8.96 40. Chitral 0.42
37. Killa Saifullah 8.9 41. Swabi 0.2
38. Washuk 7.44 42. Batgram 0.16
39. Ziarat 6.04 43. Dir Upper 0.15
40. Shirani 5.69 44. Haripur 0.03
41. Killa Abdullah 5.52 45. Abbottabad 0.02
42. Chagi 9.61 46. Mansehra 0
43. Kohlu 19.43 47. Kohistan 0
44. Mastung 10.18
45. Pishin 8.25
46. Musakhel 11.92
47. Barkhan 7.39
48. Khuzdar 13.39
49. Punjgur 7
50. Lasbella 6.81
51. Quetta 6.44
KP
52. Bannu 31.96
53. L. Marwat 13.22
54. Charsada 7.26
55. Hangu 6.55
56. Buner 5.77
57. Tank 5.34
58. Mardan 11.01
59. D.I. Khan 13.66
60. Kohat 8.47
61. Dir Lower 20.79
62. Shangla 7.98
63. Karak 7.18
64. Nowshera 7.1
65. Swat 5.68
Punjab
66. D.G.Khan 9.71

17
2.2. Malaria case management

2.2.1. Diagnostic arrangements

Public Sector involvement:

The malaria diagnosis has been integrated within health care services so that continuous care
can be provided close to the patient's home. The RHC’s and hospitals are working as
microscopy centers where as the BHU’s and CDs (in selected districts) are working as RDT
centers. The malaria control program in Pakistan (except province of Punjab being low
endemic) is following the strategy of passive malaria case detection (PCD) and treatment.

There are currently 446 public sector microscopic centers and 943 RDT centers which are
strengthen in public sector in 38 malaria high risk districts of Pakistan supported mainly through
GF to provide standardized malaria case management services as per the national guidelines.
The table below presents the province/region wise distribution of these centers. There are some
microscopy centers which are also established at well functioning Basic Health Units. However,
not all the hospitals/RHC and BHUs in the districts/agencies in Pakistan are strengthen as MC
and RDT centers. The public sector health facilities in districts/agencies where Global Fund has
provided support are also not covered 100% due to several reasons including shortage of
resources, staff unavailability in many facilities are non-functional facilities due to structure
damage.

Table 7: Province/Region wise strengthened MC and RDT centers through GF support

(2012-13)
Province No. of districts/ Microscopy center RDT centers
Regions agencies
strengthen
Covered Uncovered Strengthened Not Strengthened Not
strengthened strengthened
KPK 7 17 101 105 244 200
FATA 7(6 FR) - 100 - 185 252
Balochista 15 15 133 14 300 459
n
Sindh 6 17 112 83 214 500
*Punjab - 36 - 466 - 121
TOTAL 38 85 446 668 943 1532

18
Note: The centers which are covered will be sustained and the centers which are functional and
are not strengthen as MC or RDT will be involved in phased manner
*The districts (mainly in province of Punjab) with API<1 will be entering into elimination so RDT
centers will not be established

Table 8: List of human resource trained in MC and RDT in 38 high risk districts/agencies
(2012-13).
Province/ region # of districts/ agencies Microscopy RDT
KPK 7 79 225
FATA 7(6 FR) 77 154
Balochistan 15 116 298
Sindh 6 101 211
Total 38 373 888

Almost all the training has been carried out through GF support, as there are almost no funds
allocated by the public sector for training.

Private Sector involvement:

The private sector has been involved through GF support in malaria case management in
selected 9 districts/agencies among 38 malaria high risk districts of Pakistan. There were 119
GP/private provider involved in the selected districts supported by GF and reported 12,063
malaria case in 2013.

Table 9: Private sector case notification (9 pilot districts/agencies 2013)

Total number of pilot Districts 9
Total number of centers reporting. 119
cases screened/month/center 121
Total screened cases 94,514
Total Positive cases 12,063
Average cases/month/center 14
Total PV cases 7,991
Total PF cases 2,599
Total Mix cases 1,451

The table above shows that there is huge district wise variation among the number of cases
screened ranging from 40 to 120 cases per month. Similarly, the in-depth analysis of each of the
19
private providers reveled that there is also a wide-range of cases being reported from each
private care provider.

Considering the big private sector in the country, the role of private sector in malaria
management should not be undermined. It is important to review the current experience/model
of involving the private sector in malaria case management and should be improved for scale-
up.

Quality Assurance System

There is no national and very few fully functional provincial reference laboratories for doing
quality assurance for malaria microscopy and RDT services. In last few years there is hardly
any information available to demonstrate the quality assurance systems at district/agency level
in malaria high risk districts.

Quality assurance system at national provincial/ regional and district/agency level hardly exits

2.2.2. Treatment arrangements

The doctors and paramedics in 1,389 diagnostic centers (MC and RDT centers) are trained on
national case management guidelines. A total of 1,542 doctors and related staff from these
health facilities have been trained on treating un-complicated and complicated malaria in 38
high risk districts.

Table 10: List of human resource trained in treatment in 38 high risk districts (2012-13).
Province/ region # of districts/ Un-complicated and Complicated malaria
agencies covered case management
KPK 7 347
FATA 7(6 FR) 263
Balochistan 15 559
Sindh 6 373
Total 38 1,542

Almost all the training has been carried out through GF support, as there are almost no funds
allocated by the public sector for training.

Guidelines on case management were developed and the latest being developed by DoMC in
collaboration with Save the Children with technical support of WHO. The protocols provide the
details on treating the clinical, uncomplicated vivax, uncomplicated and complicated falciparum
and mixed infections of malaria.
20
All the essential anti-malaria drugs for the treatment of uncomplicated and complicated malaria
have been provided from public sector and through GF support. The anti-malarials is included in
the essential drug list (EDL) and also a part of essential health service package (EHSP) of the
provinces. However, there are still interruptions in the availability of drugs such as primaquine
(not manufactured locally), Inj Arthemeter/artesunate is due to non availability in local market.

Still monotherapy is used for treatment of Falciparum cases in public sector facilities which are
not strengthen in case management as per the national guidelines and also in private sector
facilities due to limited involvement.

The findings of the MIS survey shows that the treatment protocols are not completely followed
due to several reasons including high attrition of trained staff in the facilities.

2.3. Malaria prevention

2.3.1. Long lasting insecticide treated nets (LLINs)

The regular use of LLINs in moderate and low endemic situations is considered as one of the
most effective malaria prevention interventions. The MCP has recently developed LLINs
distribution strategy which focuses on universal coverage for the entire population at risk of
malaria in areas not covered by IRS. The implementing partner follows the guidelines and till
date has supplied LLIN’s through the voucher system through trained staff. The MCP
recommends the purchase of LLINs that are approved by WHOPES.

Mainly through Global Fund support in 2012-13 a large number of LLINs has been distributes in
various districts/ agencies in three provinces and FATA region. In addition, LLINs were also
distributed in flood affected districts of Punjab, KP and Sindh during 2011-2013. The table below
shows the number of LLINs procured/distributed through various funding sources.

Table 11: LLINs distributed (2012-13)

Province/region District/Agencies covered LLINs distributed
(All from GF grant) Public Sector GF Total
KPK 7 - 484,541 484,541
FATA 10 (3 FR) 6,121 287,540 293,661
Balochistan 15 - 313,646 313,646

21
Sindh 6 - 565,682 565,682
Total 38 6,121 1,651,409 1,657,530
Source: Provincial and Federal DoMC and Save the Children data, 2013

The distribution of LLINs from the public sector resources is negligible

The recent Pakistan Demographic and Health Survey (PDHS) 2013 shows that 13% of
households in sampled districts are in possession of mosquito nets which is almost double than
that reported in the previous PDHS 2007-08. Yet, only 1% of households possess at least one
insecticide treated bednet (ITN), which was almost negligible (0.1%) in the previous survey.

The MIS survey 2013 shows that among the survey households in the 38 districts, 34%
households had at least one LLIN. The highest coverage was in FATA (54%) whereas the
lowest was in KP (15%). The households possessing LLINs, 21% children of age < 5 years and
28% of the pregnant women slept under LLIN previous night.

There is still very low coverage of LLINs i.e. at least 2 LLINs per HH in the high risk districts.
Moreover, the use of LLINs in the high risk group i.e. children under 5 and pregnant women are
also very low. The procurement and distribution of LLINs is > 90% is also highly dependent on
donor support.

The LLINs were distributed in the community following a LLINs distribution strategy which was
based on voucher system to have more accountability. The table below shows the training
carried out on LLINs distribution strategy in three provinces and FATA region.

Table 12: Trainings on LLINs distribution strategy GF supported (2013)

Province/region District covered LLINs distribution strategy
KPK 7 213
FATA 10 (3 FR) 225
Balochistan 15 226
Sindh 6 121
Total 38 785
Source: Provincial and Federal DoMC and Save the Children data, 2013

22
2.3.2. Indoor residual spraying (IRS)
The use of IRS is a vital malaria prevention strategy in areas where there is high malaria
prevalence which needs to be mapped up to the level of Union Council for effective
implementation. However, currently no regular system is in place to analyse and generate the
desired information. Directorate of Malaria Control (DoMC) through its provincial/regional
partners discourage the; indiscriminate use of insecticides. This could be only possible through
careful planning of using IRS in target areas. No provincial/regional level insecticide
susceptibility survey has been carried out and sentinel sites are non-functional.

Currently 15% of the rural UCs (HOT SPOTS) in the districts/ agencies of high risk districts
having API/SPR > 5 are targeted with IRS twice a year (one round where transmission season
is short) supported by public sector and GF support. The DoMC at federal and provincial level
uses WHOPES approved insecticides and spray pumps. The MCP purchases Alpha-
Cypermathrine and Permathrine. Currently the program is planning to conduct insecticide
resistance survey the finding of which in 2015 will inform the change in insecticide selection for
IRS.

The public procurement of IRS need to be in line with national guidelines and should be
registered with Drug Regularity Authority Pakistan (DRAP).The spray is done through spray
men hired for the purpose and trained by district malaria supervisor with limited quality
assurance system in place.

The IRS commodities are purchased at federal and also provincial malaria directorate level and
sent to the districts/agencies. There is low quality of insecticides available in the market
because of loose and unmonitored regulatory system. The quality of IRS purchased through
public sector is usually checked during purchase time. The table below shows the IRS coverage
in 2013 in 38 targeted districts.

Table 13: Province/district wise coverage of IRS (Household covered in 2012-13)

Province / Region Household covered with IRS
KP 82,895

FATA 46,673

Balochistan 66,855

Sindh 75,721

TOTAL 272,144

23
Most of the household sprayed with IRS are in the 38 high risk districts and mainly supported by
the GF support. The IRS contribution from public sector is inadequate.

The MIS survey 2013 showed that overall 11% households in 38 high risk districts were sprayed
with IRS. Maximum IRS coverage was found in FATA region (18% of households were sprayed)
followed by Sindh (14%) with a lowest coverage in Balochistan (7%).
Still many households in the high risk union councils are uncovered through IRS

Table 14: List of IRS equipment in provinces/regions supported by GF (2013)

Province/ regions Districts/Agencies Spray pumps (2010-12)
covered
Sindh 6 120
KPK 7 140
FATA 10 (3FR) 200
Balochistan 15 300
Total 38 760
Most of the IRS equipment is provided through the GF support in the 38 high risk districts. There
are very few pumps provided by the public sector in these districts which are mostly non-
functional due to repair issues or are very old.

2.3.3. Larvicidal
There is limited larviciding carried out in the country during 2012-13 for the prevention of
malaria. There are very few locations in the high risk districts where larvicidal is practiced. No
proper planning is done to optimize the implementation of Larval Source Management (LSM).
No mapping is done to identify potential breeding sites for larviciding.

2.4. Behaviour change communication

Behavior Change Communication (BCC) is an important component of the Malaria Control
Program. The federal and provincial/ regional DoMC has limited capacity and resources
available for advocacy, information, education, communication and community mobilization. In
2012, BCC strategy was developed through GF support and was implemented in selected
districts. The table below reflects the BCC activities conducted in selected 38 districts of
Pakistan through GF support (2012-13)

24
Table 15: Advocacy, BCC activities and Beneficiaries Reached
District Advocacy events and Community awareness Community awareness
community based activists session at community and sessions at community and
involving LHWs, CBOs, NGOs, facility level in 38 districts facility level in 38 districts by
religious leaders, local elders, by LHWs CBOs/NGOs
elected representatives(for
community awareness to
enhance preventive and
curative services utilization in
38 districts)
Beneficiaries Sessions Beneficiaries Sessions Beneficiaries Sessions
reached reached reached
Kharan 105 7 4659 186 2375 79
Panjgoor 55 4 7780 311 4640 155
Washuk 130 9 4979 199 1994 66
Chaggai 80 5 4222 169 1679 56
Kech 75 5 4997 200 2766 92
Gawadr 109 7 6339 254 2960 99
Thatta 202 13 5304 212 3003 100
Dadu 743 50 6699 268 6412 214
Khaipur 1061 71 18951 758 20768 692
Tharparker 599 40 7430 297 7483 249
Charsadda 949 63 5835 233 8401 280
Nowshera 744 50 6408 256 7221 241
Mirpurkhas 577 38 7028 281 7141 238
Tandoallayar 789 53 7156 286 10082 336
FR Peshawar 76 5 510 20 1657 55
FR Kohat 97 6 510 20 1650 55
Fr Bannu 125 8 500 20 2407 80
FR Lakki 82 5 400 16 2537 85
FR DIK 109 7 450 18 1594 53
FR Tank 90 6 500 20 1062 35
Tank 253 17 5877 235 3320 111
DIK 321 21 8536 341 3419 114
Khyber 155 10 1444 58 3817 127
Lakki 276 18 4911 196 3303 110
Bannu 279 19 3973 159 3571 119
Pishin 268 18 8036 321 2550 85
Musa Khel 328 22 8839 354 2406 80
Zhob 203 14 6279 251 1106 37
Noshki 202 13 5105 204 1574 52
Sibbi 229 15 5920 237 1660 55

25
Harnai 145 10 3067 123 1420 47
Loralai 214 14 5215 209 1766 59
KilaSaifullah 221 15 4075 163 1536 51
Naseer Abad 253 17 6605 264 1500 50
sherani 40 3 600 24 0 0
Bajaur 304 20 11209 448 3789 126
Kurram 309 21 7253 290 4158 139
Mardan 362 24 3790 152 4138 138
Mohmand 201 13 8692 348 4537 151
Orakzai 349 23 3794 152 3625 121
SWA 269 18 3300 132 4715 157
11978 799 217177 8687 155742 5191
In addition there are other BCC activities by involving print and electronic media

o Printed materials (posters, charts, pamphlets, banners and newspaper)

o TV spots
o Radio spots

World Malaria Day is commemorated every year at the agency headquarter which helps
awareness creation on malaria issues. The Lady Health workers, school teachers, religious
scholar and health facility are involved in delivering key health messages on malaria control and
prevention. They conduct health awareness session with community members and are given
incentive of Rs 50 for interacting with each person. There are no health education sessions at
health facility level with malaria messages.

The MIS survey 2013 showed that about 87% of the respondents have heard about malaria.
Whereas the source of information was mainly from health facility (48%) followed by family
member (33%). Television was also found out to be major source of information (22%).
Maximum people (79%) relay on allopathic medicine for the treatment of malaria.

However, BCC strategy is not yet implemented in holistic way to have major impact. There is no
BCC training guidelines at national and provincial level.

There is earmarked funding for IEC/BCC and social mobilization in the PC-1. However, the
amount is dependent on funds availability. The funding level is not adequate to cover all the
BCC components at directorate and agency level.

26
2.5. Technical & managerial capacity in planning, implementation, management
of malaria control interventions

2.5.1. Program management

The federal and provincial/regional directorate of malaria control manages the program activities
in Pakistan. However, few provinces/regions are also planning to introduce Vector Born Disease
(VBD) program. After the 18th constitutional amendment the federal and provincial/regional roles
as far as malaria control interventions is concern mainly includes:

Federal Level:
1. Preparation of proposals and liaising with International agencies for securing support of
partner agencies
2. Providing technical & material resources to the provinces/regions for successful
implementation of disease control strategies, and disease surveillance.
3. Act as Principal Recipient for Global Fund support

The activities which the federal DoMC has to perform includes:

i. To coordinate malaria-related curative and prevention efforts between
provinces, Planning Commission (PC), UN partners, donors and other
stakeholders.
ii. To consolidate and support efforts of Provincial Malaria Control Programs
(MCPs) of the country through a coordinated response.
iii. To act as the primary coordinating, technical support, monitoring and
evaluation (M&E) and Central Data Coordinating Unit (CDCU) for prevention
and control of malaria in Pakistan.
iv. To provide technical support to Provincial counter-partners i.e. Malaria
Control Programs (MCPs), non-governmental organizations, community
based organizations and other stakeholders working for prevention and
control of malaria as a one of the major public health problem in Pakistan.
v. To support provinces/districts in the prevention and control of malaria in
epidemic situation and complex emergencies.
vi. To serve as the Principal Recipient (PR) for Global Fund Round Grants
(Malaria) for Pakistan and provide support as Project Management Unit and
Partners (PMU).

27
Provincial/Regional Level:
1. Coordinate with Federal DoMC in Malaria control activities
2. Secure public sector funding
3. Implement malaria control interventions as per strategic plan
4. Capacity building
5. Coordinate and supervise districts including public and private sector
6. Monitoring and Evaluation & Surveillance
7. Manage the drug supply and logistics
8. Manage Provincial/Regional Reference Laboratory

District/Agency Level:
1. Coordinate with provincial directorate of malaria control
2. Service delivery (case management, vector control and surveillance)
3. Capacity building
4. Monitor and supervise
5. Procure malaria control supplies through district budget
6. Store and Consume Logistics
7. Maintain Quality Lab Services and implement EQA
8. Prepare and submit reports

To carry out the roles at federal, provincial and district level very limited staff is available from
public sector support. The malaria control activities cannot be implemented effectively with such
a limited staff. There is a dire need to fill the gaps of technical human resource at federal,
provincial and district staff keeping in view the changing role of the program.

2.5.2. Program funding

At the federal level there is a Directorate of malaria control under the administrative control of
Ministry of national Health Services, Regulation and coordination since 2013. The Programme is
provided two types budget i.e. non-development budget that is for salaries of regular staff,
maintenance etc and the development budget for the developmental activities of the programme
through PSDP. The non-development costs are enormous, whereas the development budget is
mainly through federal and provincial PC-Is.

28
Table 16: Federal DoMC development budget from 2001-2013
Year Phasing PSDP Releases Expenditure
as per PC-1 allocation
2001-02 146.665 146.00 146.00 97.514

2002-03 30.820 31.000 31.000 25.972

2003-04 33.182 29.000 29.000 27.336

2004-05 29.509 34.000 34.000 27.199

2005-06 32.861 33.000 33.000 33.000

Total 273.037 273 273 211.021

2006-07 - 60.000 60.000 48.850

-
2007-08 - 100.00 5.00 4.7
-
Total 160.00 65 53.55

2008-09 233.69 100.00 30.0 14.966

2009-10 140.57 100.00 71.7 70.7

2010-11 99.46 100.00 31.5 30.5

2011-12 92.82 Nil Nil Nil

2012-13 92.08 Nil Nil

Total 658.62 300 133.2 116.166

In last 5 years the allocations remain low and so were the releases. Same phenomena have
been observed in the case of provinces and regions.

During last few years through the provincial and regional PC-1s about Pak Rs 1093 million has
been allocated from which about 45% has been released. In addition to the public sector
commitment the programme has been successful in securing the donor commitment through
increased funding to address the gaps. The main source of funding is the Global Fund and to
some extent WHO.

29
Through Global Fund (SSF), the Malaria Control in Pakistan has secured about US $ 52 million
from which about 31 million was for phase 1. The purpose was to deliver comprehensive
malaria control intervention including early diagnosis and treatment, vector control BCC, etc in
38 high risk-districts in the three provinces of Pakistan (Balochistan, KP and Sindh) and FATA
region.

At provincial and regional level the allocation of public sector support is very low (see the details
in the provincial/regional strategic plans).

2.6. Quality assured strategic information (epidemiological, entomological and

operational)

The malaria related information has been reported from the provinces/ regions through various
data generation systems. This includes;
1. District Health Information System (DHIS)
2. Malaria Information System (MIS)
3. Disease Early Warning System (DEWS)
4. Facility Monthly Report (FM) 1-3

The routine data is reported through the DHIS reports system from the primary and secondary
health care facilities for the year 2013 shows that 3,190,972 patients were diagnosed as clinical
malaria cases. A total of 1,865,773 slides/RDTs were examined of which 141,943 were MP
positive. There were 46,013 admissions while 244 deaths were reported due to malaria.

The MIS data shows that 4,561,825 slides/RDTs were examined from which 281,755 were
positive with PV 223,660, PF 46,067 and Mix 12,028.

In addition there are new forms FM1-3 which are also introduced in the GF supported 38
malaria high risk districts which are in-depth and also provide age disaggregated information.
During 2013 from this system 247,958 confirmed malaria cases were reported.

There are several trainings carried out in the high risk districts on MIS during 2012-13. The table
below shows the details of trainings carried out.

30
Table 17: Trainings on MIS (2012-13)
Province/region District covered MIS
KPK 7 345
FATA 10 (3FR) 225
Balochistan 15 439
Sindh 6 309
Total 38 1318
Source: Provincial and Federal DoMC and Save the Children data, 2013
None of the above training has been supported financially through public sector

The suspected malaria is also reported through DEWS supported by WHO.

There are variations in the type of information received from the three sources. Moreover, all the
facilities are not reporting in MIS and new FM1-3 forms. Efforts are required to standardize the
data collection and reporting system from health facilities which are diagnosing and treating
malaria cases so that the complete malaria situation in Pakistan can be reflected.

2.7. Malaria treatment and prevention services in humanitarian crises,

emergencies and cross boarder
Many provinces/regions in the country are prone to natural disasters and emergencies.
Currently few districts/agencies in the country (mainly in KP and FATA region) are also going
through a phase of insurgency which has created a large number of internally displaced
population (IDP). Large population movements are putting additional burdens on already
resource stretched administration and service providers. Malaria is often not considered a
priority health problem in an acute phase of a crisis. All such situations can make the country
very significant in terms of malaria situation and can result to an epidemic at any stage. There
are national guidelines for malaria in case of emergencies. However, there are no arrangements
available to implement this guideline effectively.

There are several districts/agencies in Balochistan and FATA region which have borders with
neighboring countries like Afghanistan and Iran from where movement of people across borders
is quite frequent for work purposes. Daily thousands of Afghan move into Pakistan via Torkham
in Khyber, Ghulam Khan in NWA, Nawa pass in Mohmand & Azam Warsak in SWA. Huge
number also cross border from Parachinar in Kurram Agency, similarly Chaman border. No

31
mechanism and guidelines in place to address the issue of imported malaria cases through
cross border movement.

32
3. SWOT ANALYSIS
STRENGTHS
3.1. Malaria case management and treatment
-Up-dated Case
management
guidelines available
-446 MC and 943
RDTs centers
strengthen
-4,561,825
slides/RDTs prepared
in 2013 and reported in
MIS
-281,755 malaria
cases confirmed in
2013
-Availability of first-line
co-formulated
treatment
-Antimalarial drugs and
malaria diagnosis
provided free of charge
at public health
facilities
-Expansion of
diagnostic coverage
using RDT
-Doctors, Microscopist
and technicians trained
on national guidelines
-Private sector getting
involved in malaria
care (12,000 confirmed
case reported in 2013)
-Updated guidelines on
malaria in pregnancy
WEAKNESS OPPORTUNITIES THREATS
-Clinical diagnosis still -Devolution has -Lack of public sector
a common practice happened and funding through PC-1
(3,190,972 clinical strategic planning is an -Inadequate
cases reported in DHIS opportunity to express knowledge regarding
in 2013) demand the management of the
-About 668 MC and -VBD program is malaria
1,532 RDTs centers gaining priority -Inadequate resources
still not strengthen -Additional financial for the management of
-Limited adherence to resources available cases and supervision
the treatment through the GF of health workers
guidelines -Expansion of -Short shelf life of the
-Negligible private diagnostic capacity of first line treatment and
sector involvement in HF including MCH few drugs not available
malaria control centers in GF funded in the open market
-Shortage of laboratory and non-GF supported -Inappropriate
technicians in health districts/agencies prescription/ use of
facilities mainly PHC -Collaboration with drugs
-Rapid turnover of other departments -Incorrect use of
trained staff and such as MNCH on antimalarial drugs by
inconsistent IMNCI and PCPNC on patients
supervision of in-service training and -Self-medication with
laboratory technicians. supervision antimalarial drugs
-Non existence of
supervision of case
management activities
-Lack of QA system for
microscopic diagnosis
and RDT at national,
provincial and district
levels
-Use of oral artemisinin
monotherapy in the
private sector
-No focal points
working on case
management
-Acute shortage of
electricity which
hampers MC
33
STRENGTHS WEAKNESS OPPORTUNITIES THREATS;

3.2. Malaria prevention (LLINs, IRS and Larvicidal)

-LLINs distribution -Inadequate vector -Government regular -Natural disasters

strategy available control personnel in annual budget for IRS e.g. floods can create
- 1.6 million LLINs the provinces/districts -Funding from GF a shortage
distributed in 2012-13 -LLINs program donor -Effective insecticides -Insecticide
-IRS use in place in and partner dependent against local vectors resistance
targeted areas, -Inadequate transport -Sustainability of
272,144 HH sprayed and storage facilities at quality IRS -LLINs
-Larvicidal/LSM provincial/regional and program donor and
experience district/agency level partner dependence
-No regular staff to
supervise IRS
activities
-Lack of a logistics
management system
for RDTs
-Larvicidal/LSM not
implemented
effectively

3.3. BCC, IEC and advocacy

-BCC strategy -No focal point at -The current plan will -Lack of funding
available federal/provincial express the demand for -Lack of interest at
-BCC activities directorate level to deal effective BCC district level
implemented in the with BCC -Opinion makers at local
provinces/region -Lack of funds to carry level exists which can be
-Commemoration of out BCC activities involved in BCC
World Malaria day -Limited experience -NGO, donors, private
including a press with implementing BCC sector have shown
conference -Impact assessment interest.
not done

34
3.4. Programme Management
-Federal and -Shortage of technical -Devolution has provided -Poor staff
provincial/regional and administrative staff an opportunity to motivation due to low
malaria directorates at provincial/regional strengthen program salaries.
functional and district/ agency -Current plan will -Issues related to
-Full-time program level document the need for sustainability of the
managers in-place -Inadequate supplies human resource program
-Inadequate -VMD program gaining -PC-1 and not in
collaboration between importance regular budget
MCP and other DoH -Support from major -Frequent changes
Units funding agencies in management of
-Lack of evidence expected the program
based planning -Political involvement

STRENGTHS WEAKNESS OPPORTUNITIES THREATS

3.5. Surveillance and monitoring and evaluation

MIS provides routine -MIS not capturing the -Program sensitized to Districts/agencies
malaria program data entire implement standardized have more than one
on monthly basis from provincial/regional MIS in selected districts reporting system
MC and RDT centers situation which can increase
-FM1-4 not work load
implemented across
the board
-Lack of skills in
monitoring and
evaluation by
managers in malaria
control activities
-Limited experience of
existing staff to
implement monitoring
and evaluation
activities
-Low quality data from
routine systems.

3.6. Procurement and supply management

Procurement policies -Small storage New strategic plan will -Inadequate

available capacity at address the Gap funding for malaria
provincial/regional -Procurement
and district/agency process is long
level
-Inadequate systems
for quantification of
LLINs and RDT’s
35
 -Inadequate logistics
for transportation of
malaria commodities

3.7. Epidemiology and entomological data

Existence of an -No standardization of -Current plan will -Staff are not

epidemiological data address the Gap motivated
surveillance system -No data on -PC-1 and donor -Poor coordination
that provides monthly entomology support would help between program and
data on malaria burden -Quality of data is a big address the issue of partners
issue comprehensive and
-Lack of plan for quality data reporting
studies required on
malaria

3.8. Epidemic preparedness & response and Cross border situation

Malaria surveillance in -Malaria surveillance -Current plan will -Poor coordination

place at system not yet address the Gap between program and
provincial/regional involving use of -PC-1 and donor partners
level epidemic thresholds for support would help
early detection of address the
malaria epidemics. intervention related to
-Absence of an early epidemic preparedness
warning system for and response and
prevention of malaria malaria in cross-border
epidemics. situation
-No arrangement to
address malaria in
cross-border situation
-Unavailability of buffer
stock

36
4. GAP ANALYSIS
4.1. Inadequate malaria diagnostic service network
4.1.1. 4,561,825 slides prepared in 2013 among which 281,755 were confirmed
as malaria cases reported in MIS whereas the FM1 information from 38 districts
shows 247,958 confirmed malaria cases.
4.1.2. The cases reported in MIS and FM1-3 are not reflecting the total malaria
picture of the country as all the health facilities are not strengthen
4.1.3. 38 malaria high endemic districts are not comprehensively involved in
standardized malaria case management
4.1.4. 28 malaria high endemic districts (API/SPR >5), 10 malaria moderate risk
districts (API between 1-5) and 47 malaria low risk districts (API< 1) are not
strengthen for malaria case management
4.1.5. 668 MC centers and 1532 RDT are not strengthen in diagnosing malaria
cases as per the national guidelines in the country
4.1.6. 446 MC and 943 RDTs centers strengthen through GF grant in 38 high
risk districts are working sub-optimal due to lack of quality assurance system and
high attrition of staff.
4.1.7. The MC and RDT centers hardly perform 2-3 tests per day. BER is very
low.
4.1.8. DHIS still reports 3,190,972 diagnosed as clinical malaria (many public
sector facilities either not fully strengthened or involved as diagnostic centers)
4.1.9. Lack of Knowledge and skills of microscopists and health staff conducting
RDTs to diagnose malaria (mainly due to rapid turnover of trained microscopist
and trained technicians)
4.1.10. Negligible private sector involvement in malaria control. Only 119 private
providers involved in 9 high risk districts
4.1.11. Shortage of laboratory technicians in health facilities mainly PHC
4.1.12. Lack of regular supply of electricity which highly effect the microscopy
services
4.1.13. Radical treatment for P.vivax as per national guidelines has not been
followed in centers which are not currently strengthen as per national guidelines
4.1.14. Supervision of case management not performed
4.1.15. National case management guidelines, training manual and tools needs
to be up-dated

37
 4.1.16. WHO T3 (Test, Treat and Track) strategy not fully operational

4.2. Treatment services not as per the protocols

4.2.1. Knowledge of physicians on management of uncomplicated, severe malaria and
malaria in pregnancy at PHC level is inadequate due to un-trained and rapid turnover of
trained health care providers.
4.2.2. No mechanism and guidelines for ensuring patient treatment compliance (DOT)
4.2.3. Availability of drugs such as primaquine, Inj Artesunate in un-regulated local
market. Primaquine not manufactured locally.
4.2.4. In many instances, physicians prescribe anti malaria drugs without laboratory
support, resulting in relapses and recrudescence and potentially posing life threat to the
patient
4.2.5. Lack of proper drug testing system to ensure the quality of the products,
information on bio availability is lacking. Currently the drugs are tested at few
laboratories
4.2.6. Lack of linkages between Federal and provincial/regional Drug Controller Offices.
4.2.7. Private sector hardly involved in malaria care provision hence not following the
national treatment guidelines
4.2.8. Guidelines for treatment of malaria needs to be up-dated
4.2.9. Shortage of anti-malarial drugs expected to address enhanced case finding and
demand of additional diagnostic centers

4.3. Quality assurance arrangement sub-optimal

4.3.1. There is hardly any functional reference labs in the country (Sindh province has a
reference laboratory but not properly linked with districts)
4.3.2. Current QA system is not satisfactory
4.3.3. There is no dedicated staff available at reference labs at national and provincial
level
4.3.4. There is limited equipment and logistic facilities available for QA
4.3.5. At the district/agency level there is currently limited capacity/arrangement for QA.
(capacity building, including logistic support)
4.3.6. RDT quality assessment capacity not available
4.3.7. No guidelines on RDT quality assurance mechanism

4.4. Universal coverage of LLINs not achieved

4.4.1. Requirement of LLINs is based on assumptions.
38
 4.4.2. 1.6 million LLINs (10% of the country need) have been distributed in the selected
districts of the country during 2012-13. About 95% of the overall LLINs were arranged
through donor support i.e. GF. This implies that the LLINs supplies are heavily dependent
on donor support.
4.4.3. It is estimated that there is a gap of about 21.0 million LLINs are required by
2020 to have a universal coverage (including replacement) in all 66 high malaria endemic
districts/ agencies in the country along with the needs of the people living in moderate/low
risk 57 district of the country with malaria foci and prone to natural disasters. -
4.4.4. LLINs not fully distributed as per the National LLINs distribution strategy
4.4.5. Storage capacity and practices for LLINs is inadequate. Rental warehouses are
not following the good storage standards. At provincial/regional level there is only one store
for all health items. Limited arrangements available at district/ agency level.
4.4.6. Sub-optimal use of LLINs at household level especially high risk population
(almost 80% children under 5 years and 70% pregnant women not slept under LLINs last
night)

4.5. IRS coverage is low in high malaria prevalent UCs:

4.5.1. The IRS coverage is only 11% currently in high malaria prevalent UCs in high
risk districts
4.5.2. Proper estimation not done to cover the highly endemic agencies, UC and
number of structures to be sprayed
4.5.3. Requirement of IRS calculation is based on assumptions.
4.5.4. No proper IRS quantification system and guidelines at regional level exits.
4.5.5. Micro-planning is done at the agency level by Malaria Superintendent, but there
are limitation in planning and supply of IRS
4.5.6. Few provinces/regions have entomologist available to address technical issues
related to calculation and proper use of IRS in the targeted areas.
4.5.7. Sentinel sites for monitoring vector resistance to insecticides does not exists
4.5.8. No arrangement for quality testing of active ingredient/ formulation and bi
products of IRS
4.5.9. Human resource for spraying not available. It is required on daily wage basis, but
the required number of HR for spray and supervisory support staff at district/
agency level is not always available

39
 4.5.10. Limited equipment is available at district/agency level for IRS spraying and major
repairs are required to make available spray pumps operational
4.5.11. There is usually shortage of insecticides in the district/agency

4.6. Larvicidal not implemented effectively

4.6.1. No proper mechanism in place for the larvicidal control
4.6.2. No guidelines and arrangements at national, provincial and regional level to
address LSM
4.6.3. Mapping of the permanent breeding sites missing
4.6.4. Quantification and frequency of larviciding for each district/agency (high risk) is
not available

4.7. Community mobilization not effective

4.7.1. Many patients are still not using the public sector health facilities for the
treatment of malaria
4.7.2. Huge gaps exits in term of providing information and mobilizing the house hold
using LLINs including high risk populations (only 21% children < 5 years and
28% pregnant women slept under LLINs last night)
4.7.3. BCC tools and materials either not up-dated and if available are not implemented
effectively
4.7.4. Involvement of LHWs in suspect identification and referral almost non-existing.
4.7.5. The impact of exiting BCC activities has not been assessed
4.7.6. WHO COMBI strategy for BCC not fully implemented

4.8. Funding mainly depending on external support

4.8.1. Not enough public sector funds are allocated at federal, provincial and regional
level for malaria control interventions in the current PC-1
4.8.2. In the available budgets there is almost no money for capacity building
4.8.3. PC-1 releases are not timely and inadequate
4.8.4. Amount for LLINs and IRS is inadequate
4.8.5. No funding available to hire technical and administrative human resource
4.8.6. Many components of malaria are depending on international funding.

4.9. Program management

4.9.1. The malaria program has limited monitoring and evaluation system.

40
 4.9.2. Monitoring guidelines and tools are not adequate and not available across the
board.
4.9.3. There are no M&E officers through public sector support
4.9.4. VBD program not initiated
4.9.5. No dedicated focal point for malaria at district/agency
4.9.6. Inadequate logistic support to monitor malaria control activities in
districts/agencies

4.10. Malaria control problems are not addressed through operational research
4.10.1. Data collected from malaria control, not fully analyzed to hypothesize for issues
to be addressed through operational research
4.10.2. No up-dated agenda for operational research at federal, provincial and regional
level

4.11. Storage capacity for drugs and supplies not as per standards
4.11.1. Currently no separate stores available at provincial, regional and district/ agency
level to store anti-malarial drugs, LLINs and IRS
4.11.2. Good storage practices are not completely implemented in the districts/agencies
(space, inventory system, temperature, etc)

4.12. Significant issues in training in malaria control

4.12.1. There is almost no public sector funding currently available to conduct trainings
on various malaria control interventions through public sector support
4.12.2. The training agendas are often not well established
4.12.3. Planning of training activities is not pro-actively shared with the districts/
agencies and is not always based on bottom-up approach.
4.12.4. No core of provincial/regional trainers has been established. The trainers that
need to be involved in training activities are identified on ad hoc basis.
4.12.5. No feedback system exiting to access the impact of trainings and to plan
refresher courses
4.12.6. At district/agency level (high and moderate risk districts/agencies) there is more
than 50% staff which needs to be trained on various malaria control interventions
such as malaria case management, prevention and surveillance activities.

41
4.13. Epidemiological and entomological information inadequate
4.13.1. There is no standardize recording and reporting system exits to report malaria
diagnosis and treatment activities in health facilities currently not implementing
malaria control interventions.
4.13.2. The current three reporting systems have no uniformity of information
4.13.3. No uniform case definitions exit for the three parallel disease reporting systems
(DHIS, MIS, and DEWS).
4.13.4. There is wide variation in suspected and confirmed malaria cases reported in
three parallel systems
4.13.5. There is no standardize regular system exists to monitor the distribution and use
of LLINs at the household level and IRS coverage (more based on project
specific tools)
4.13.6. The sentinel sites for vector bionomics do not exist
4.13.7. No information exists on breeding, biting and resting habits of mosquito
4.13.8. Regular reporting on vector density, susceptibility, entomological inoculation
rates, sporozoite rates and human blood index is not done
4.13.9. No soft ware system/GIS introduced to capture malaria related information in the
facilities/community
4.13.10. Weak use of data for decision making and inadequate training and human
resource in malaria surveillance, monitoring and evaluation.
4.13.11. There are also delays in data submission at all level.
4.13.12. Data is not readily available for the managers for their use and the quality of
the data is low
4.13.13. Third party evaluation system not in place

4.14. Weak system for malaria control services in humanitarian crises,

emergencies and cross border situation
4.14.1. No national guidelines and training material available on malaria emergency
preparedness and response in humanitarian crises and natural disasters
4.14.2. No policy exists to address malaria control services in population that moves
across the border of Afghanistan and Iran on regular basis
4.14.3. No contingency plans exits to address supplies needed for response (buffer
stock) to malaria emergencies at provincial, regional or agency level
4.14.4. No organization or focal point exists at provincial, regional or agency level to lead
malaria emergency preparedness and response

42
4.14.5. No training in emergency preparedness and response has been conducted
related to malaria
4.14.6. Lack of linkages with currently organization such as National Disaster
Management Agency (NDMA)
4.14.7. The present PC-1 have no allocation to address emergencies and IDP

43
5. MALARIA CONTROL PROGRAM PAKISTAN: VISION, GOAL AND
OBJECTIVES
The strategic interventions and activities are organized under the six program objectives.
Addressing these objectives through specific strategic interventions and activities would help to
achieve the national goal.

Malaria Control Strategic Plan Pakistan 2015-2020- AT A GLANCE

GOAL

By 2020, reduce the malaria burden by 75% in high and moderate

endemic districts/agencies and eliminate malaria in low endemic
districts of Pakistan

OBJECTIVES

To achieve <5 API in high endemic To achieve <1% API within moderate To achieve Zero API within low
areas of province of Balochistan, endemic districts of Balochistan, endemic districts of Sindh, KP and
Sindh, KP and FATA region by 2020 Sindh, KP and Punjab by 2020 Punjab by 2020

OUTCOMES

At least 80% of 100% of health At least 80% of All the More than 80% At least 80% of At least 80% of
those suffering facilities with the private suspected of households households in people in high
from un- no reported care providers malaria cases in high risk of high risk of malaria
complicated stock-outs of involved in visiting public malaria get at malaria get endemic
&complicated nationally malaria case sector facilities least one LLINs sprayed with districts know
malaria start recommended management get their blood IRS annually the cause,
getting antimalarial have started examined with symptoms, and
standardized drugs during reporting microscopy or preventive
and free of cost the past three confirmed RDT (BER measures for
anti-malarial months malaria cases >10%) malaria
treatment

IMPACT

Bring down annual incidence Bring down annual incidence Bring down annual incidence At least 50% reduction in
of malaria to less than 5 of malaria to less than 1 case of malaria to Zero per 1000 mortality due to malaria by
cases per 1000 population in per 1000 population in 10 population in 47districts by the year 2020, taking 2013 as
66 districts/agencies by 2020 districts by 2020 2020 baseline

44
5.1. Vision
Malaria free Pakistan

5.2. Goal
By 2020, reduce the malaria burden by 75% in high and moderate endemic districts/agencies

and eliminate malaria in low endemic districts of Pakistan

5.3. Objectives

1. To achieve <5 API in high endemic areas of province of Balochistan, Sindh, KP and

FATA region by 2020

2. To achieve <1% API within moderate endemic districts of Balochistan, Sindh, KP and

Punjab by 2020

3. To achieve Zero API within low endemic districts of Sindh, KP and Punjab by 2020

SPECIFIC OBJECTIVES:
1) To ensure and sustain the provision of quality assured early diagnosis and prompt
treatment services to >80% at risk population by 2020
2) To ensure and sustain coverage of multiple prevention interventions (IRS, LLINs & and
other innovative tools and technologies) to 100% in the target high risk population as per
national guidelines and coverage in foci in moderate and low risk districts by 2020
3) To increase community awareness up to 80% on the benefits of early diagnosis and
prompt treatment and malaria prevention measures using health promotion, advocacy
and BCC intervention by 2020
4) To enhance technical and managerial capacity in planning, implementation,
management and MEAL (Monitoring, Evaluation, Accountability and Learning) of malaria
prevention and control intervention by 2016
5) To ensure availability of quality assured strategic information (epidemiological,
entomological and operational) for informed decision making and; functional, passive and
active case based weekly surveillance system in all low risk districts by 2017
6) To ensure provision of malaria prevention, treatment and control services in
humanitarian crises, emergencies and cross-border situation

45
5.4. Outcome Indicators
5.4.1. At least 80% of those suffering from un-complicated and complicated malaria
start getting standardized and free of cost anti-malarial treatment from public sector
facilities, by the year 2016
5.4.2. 100% of health facilities with no reported stock-outs of nationally recommended
antimalarial drugs lasting more than one week at any time during the past three months
5.4.3. At least 80% of the private care providers involved in malaria case management
have started reporting confirmed malaria cases, by the year 2016
5.4.4. All the suspected malaria cases visiting public sector facilities get their blood
examined with microscopy or RDT (BER >10%)
5.4.5. More than 80% of households in high risk of malaria get at least one LLIN, by
the year 2016
5.4.6. At least 80% of households in high risk of malaria get sprayed with IRS annually
by 2017
5.4.7. At least 80% of people in high malaria endemic districts know the cause of,
symptoms of, and preventive measures for malaria in target districts of Pakistan.

5.5. Impact Indictors

5.5.1. To bring down annual incidence of malaria to less than 5 cases per 1000
population in 66 districts/agencies by 2018
5.5.2. To bring down annual incidence of malaria to less than 1 case per 1000
population in 10 districts by 2018
5.5.3. To bring down annual incidence of malaria to Zero per 1000 population in
47districts by 2018
5.5.4. At least 50% reduction in mortality due to malaria by the year 2018, taking 2013
as baseline

5.6. Target
To achieve by the end of 2020, API<1 per 1000 population in entire country

5.7. Strategic approach and interventions

The malaria control interventions are developed and will be implemented following the strategic
approach based on key interventions outlined in the two tables below:

46
Table 18: Strategic approach
Stratum Definition Strategies (Program areas)
Stratum 1 Districts/Agencies with • Epidemiological surveillance and disease
API/SPR > 5 management i.e. uncomplicated malaria (T3—
Test, Treat and Track).
• DOT for radical treatment
• Management of severe malaria cases by
strengthening of district and sub-district
hospitals and quality referral services.
• IVM by IRS and LLIN distribution supplemented
by LSM, so as to ensure universal coverage of
the entire high risk population.
• Entomological Surveillance
• Supportive interventions including BCC
activities through community and NGO
involvement.
• Involvement of private health care providers
• Inter sectoral/departmental linkages
Stratum 2 Districts/Agencies having API • Epidemiological surveillance and disease
between 1-5 management (T3—Test, Treat and Track).
• DOT for radical treatment
• Management of severe malaria cases by
strengthening of district and sub-district
hospitals and quality referral services
• Screening of migrants.
• IVM by source reduction through environmental
management (mechanical and source
reduction) and LLINs and IRS to address
epidemic/emergency.
• Entomological Surveillance
• Supportive interventions including BCC
activities through community involvement and
NGOs.
• Involvement of private health care providers
• Community and NGO involvement.
• Inter sectoral/departmental linkages
Stratum 3 Districts API < 1 • Epidemiological surveillance and disease
management (T3—Test, Treat and Track).
• DOT for radical treatment
• Active, passive and sentinel surveillance with
focus on quality surveillance
• Entomological Surveillance
• Screening of migrants.
• Vector control through community involvement
• Supportive interventions including BCC
activities through community involvement and
NGOs.
• Inter sectoral/departmental linkages

47
Table 19: Malaria program intervention outline
Item Control Programme Pre-elimination Elimination Programme
Programme
Goal Reduction of burden in Halt the local Halt the local transmission
morbidity and mortality transmission
Purpose Reduce Malaria Reduction of parasite Reduce number of active foci to
disease burden to a reservoir and halting of zero
level where malaria is local transmission to Reduce number of locally
not a public health point where acquired cased to zero
problem transmission occurs in
localized foci, enabling a
targeted elimination
programme aimed at
foci
Transmission Reduce transmission Reduce transmission Reduce transmission from
Objective intensity from existing cases existing cases
Unit of Community at Union Foci Locally acquired and imported
intervention Council level cases
Milestone for SPR <5% in suspected <1 cases per 1000 Zero locally acquired cases
transition to malaria cases population at risk per
next year
programme
type
Reporting -Standardized monthly -Standardized weekly -Standardized weekly malaria
(Surveillance) malaria reporting proxy malaria reporting reporting (electronic means)
Data source data: health facility (electronic means) -Notification reports, Individual
data proxy data: health case investigation Genotyping
-Confirmatory data: facility data notification Quality control along reporting
population based reports chain
surveys -Confirmatory data:
-Quality control along population based
reporting chain surveys
-Quality control along
reporting chain
Case-Finding Passive system of Passive surveillance Passive surveillance plus active
(Surveillance) surveillance based on plus active case case detection to trace
people presenting at detection to trace additional infections the
health facilities additional infections in community (symptomatic &
the community asymptomatic)
(symptomatic &
asymptomatic)
Case -Free-of-charge -Free-of-charge -Free-of-charge diagnosis and
Management diagnosis and diagnosis and treatment treatment for all malaria cases
treatment for all for all malaria cases -Implementation of new drug
malaria cases -Universal Coverage policy;
-Strengthening and -Updating National -Routine QA/QC expert
scaling of services to Implement guidelines for microscopy;
universal coverage - radical treatment of P. -Active case detection;
QA/QC of laboratory falciparum -Monitoring anti-malarial drug
diagnosis 100% cases resistance

48
Item Control Programme Pre-elimination Elimination Programme
Programme
(microscopy/RDT) confirmation by -Radical treatment/ DOT by
-Clinical diagnosis microscopy, LHW
(where MC/RDT not -Microscopy QA/QC:
available) -Monitoring anti-malarial
-Monitoring anti- drug resistance
malarial drug - DOT by LHW
resistance
- DOT by LHW
Vector -Ensure and sustain -Geographical -Geographical reconnaissance;
control and 80% coverage of reconnaissance; -Vector control to reduce
malaria multiple prevention -Total IRS coverage in transmission in residual active
prevention interventions (IRS, foci; IVM and universal and new active foci
LLINs under IVM coverage of LLINs as -Vector control to reduce
framework. complementary receptivity in recent foci;
-Entomological measures in specific -Outbreak preparedness and
surveillance; situations; response;
-Epidemic -Epidemic preparedness -Entomological surveillance;
preparedness and and response -Prevention of malaria in
response -Entomological travelers
surveillance
Monitoring -Improve surveillance -GIS-based database on -Case investigation and
and and national coverage cases and vectors classification
evaluation Country profiles -Elimination database -Foci investigation and
-Malaria indicator central records bank - classification
surveys (MIS,PDHS) Malaria surveys -Genotyping, isolate bank
Health -100% access to -100% access to -100% access to services
system services services engaging -Full cooperation of private
-Health system private sector sector (case reporting plus
strengthening -Control of OTC sale of management No NTS sale of
(coverage, private and anti malarial mono anti malaria medicines
public sectors, QA) therapies) -Parallel reporting and service
-Parallel reporting and delivery (e.g. dedicated malaria
service delivery (e.g surveillance, community health
dedicated malaria workers) at provincial/regional
surveillance, community and district level for period of
health workers) at elimination.
provincial/regional and
district level for period of
elimination.

Programmatic -Integration with other -Development of -Implementation of elimination

issue health programme for Elimination programme
delivery of Legislation, Regional
interventions and BCC issue
-Domestic/external -Mobilization of
funding domestic funding
-Establish malaria
elimination committee
-Reorientation of health
programme implementation of
updated drug policy, vector
control, active detection of
cases
malaria elimination committee:
-Manage malaria elimination
data base
Repository of information
49
Item Control Programme Pre-elimination Elimination Programme
Programme
facility staff Periodic review
Oversight
-Reorientation of health facility
staff
Imported -Limited cross-border -Cross-border initiative -Cross-border initiative to
Cases communication with to maximize control maximize control
neighboring operations in operations in neighboring
provinces/Countries, neighboring provinces/ provinces/ countries,
-No operational countries, -Limiting transmission and risk
collaboration. -Limiting transmission of importation in border regions
and risk of importation in
border regions

50
6. STRATEGIES, INTERVENTIONS AND LIST OF ACTIVITIES
The section below documents the key strategies and intervention in line with the six specific
objectives. Moreover, it provides a list of activities which are required to address the
intervention. The quantification and phasing of all the activities is given in the work plan.

Objective 1: Ensure and sustain the provision of quality assured early diagnosis and prompt
treatment services to >80% at risk population by 2020

Strategy
6.1. Sustain and expand quality assured diagnosis of all suspected malaria
cases in high, moderate and low risk districts

Table 20: API projection 2015-2020

Baseline 2015 2016 2017 2018 2019 2020
2013
Annual Stratum-I 5.74 7.48 9.72 7.8 5.00 4.00 3.00
Parasite Stratum-II 1.28 1.7 2.20 1.7 1.38 0.83 0.50

Incidence
Stratum-III 0.09 0.12 0.16 0.12 0.10 0.08 0.06
(API)

Intervention
6.1.1. Strengthen the existing 446 microscopy centers and 943 RDTs centers for quality
assured microscopy and RDTs in currently 38 high risk districts to increase case findings

List of Activities:
6.1.1.1. Actively screen fever cases visiting the public sector health facilities for
suspected malaria
6.1.1.2. Basic and Refresher training of doctors on case management guidelines
6.1.1.3. Basic and Refresher training of microscopists and technicians on examining
slides and conducting and reading RDTs
6.1.1.4. Arrange solar microscopes for the MC centers (at least 50% of the peripheral
MC centers)

51
Intervention
6.1.2. Establish new diagnostic centers in the districts/agencies i.e. 668 MC centers
and new 1,523 RDTs centers in health facilities (only in high and moderate risk
districts)of public sector by 2016-17 including facilities managed by PPHI

Table 21: RDTs required (2015-2020)

2015 2016 2017 2018 2019 2020
No of RDT No of RDT No of RDT No of RDT No of RDT No of RDT
Stratum I Punjab 62,550 82,559 74,576 73,020 59,334 45,198
Sindh 552,846 660,906 710,194 470,343 423,930 375,930
KPK 505,351 594,341 656,410 405,072 373,230 340,287
Balochistan 343,466 411,097 440,848 293,436 264,078 233,745
FATA 179,178 198,685 241,668 112,950 114,732 116,541

Stratum II Punjab 62,360 82,420 80,460 114,072 105,952 97,488

Sindh 178,120 235,400 229,800 325,794 302,560 278,352
KPK - - - - - -
Balochistan 4,820 6,370 6,216 8,820 8,192 7,536
FATA - - - - - -

Stratum III Punjab - - - - - -

Sindh - - - - - -
KPK - - - - - -
Balochistan - - - - - -
FATA - - - - - -

Total Punjab 124,910 164,979 155,036 187,092 165,286 142,686

Sindh 730,966 896,306 939,994 796,137 726,490 654,282
KPK 505,351 594,341 656,410 405,072 373,230 340,287
Balochistan 348,286 417,467 447,064 302,256 272,270 241,281
FATA 179,178 198,685 241,668 112,950 114,732 116,541

1,888,692 2,271,778 2,440,172 1,803,507 1,652,008 1,495,077

52
List of Activities:
6.1.2.1. Assess the health facilities for their scope to work as potential
Microscopy Centers or RDTs centers
6.1.2.2. Establish new MC centers in at least 50% (334) of the remaining health
facilities in districts
6.1.2.3. Establish new RDTs centers in at least 50% (760) of the remaining
health facilities in the districts
6.1.2.4. Provide MC and reagents and also RDTs to the selected health facilities
to functions as diagnostic centers
6.1.2.5. Train doctors on case management guidelines
6.1.2.6. Train microscopists and technicians on MC and RDTs
6.1.2.7. Train paramedics on recording and reporting (using FM 1-FM3)
Intervention
6.1.3. Establish diagnostic centers in selected private sector providers (General
Practitioners and Private Hospitals) in high and moderate malaria risk districts

Table 22: Private sector involvement (2015-2016)

2015 2016
No of Participants No of Participants
Stratum I Punjab 10 10
Sindh 60 60
KPK 70 70
Balochistan 145 145
FATA 50 50

List of Activities:
6.1.3.1. Map the GPs and private hospitals in all the 76 districts/agencies
6.1.3.2. Assess the GPs and private as potential malaria diagnostic centers
6.1.3.3. Establish new MC or RDTs centers in selected at least 50-100
GPs/Private hospitals per districts
6.1.3.4. Provide solar microscopes and reagents/chemicals to the selected
Microscopy Centers
6.1.3.5. Provide RDTs to the selected health facilities to functions as RDT
centers
6.1.3.6. Establish referral linkages between community to PHC up to secondary
and tertiary care hospital
53
 6.1.3.7. Train doctors on case management guidelines including complicated and
uncomplicated malaria
6.1.3.8. Train microscopists on doing blood slides examination for MP
6.1.3.9. Train technicians on RDTs
6.1.3.10. Train paramedics on recording and reporting (using FM 1-FM3)
6.1.3.11. Provide anti-malarial drugs for severe/complicated malaria and
uncomplicated malaria (depending on type of health facility)
6.1.3.12. Replenish drugs and supplies on regular basis
6.1.3.13. Refresher trainings for doctors, microscopist, technicians
Strategy
6.2. Strengthen anti-malarial supply at the district/agency level and improve
treatment practices
Intervention
6.2.1. Strengthen the current storage and distribution capacity of national, provincial,
regional and district level stores to manage uninterrupted supply of anti-malarial drugs
and injections, LLINs and IRS

List of Activities:
6.2.1.1. Assess the current capacity of national, provincial, regional and district
stores for capacity and good practices for anti-malarial drug, LLINs and IRS
storage
6.2.1.2. Enhance the capacity of stores for storing anti-malarial drugs, LLINs and
IRS
6.2.1.3. Establish structured mechanism to distribute the drug and supplies
distribution mechanism between stores and health facilities
6.2.1.4. Establish linkages with the drug testing organizations
6.2.1.5. Arrange adequate supply of anti-malarial drugs to address the future
demand of confirmed malaria cases
6.2.1.6. Establish electronic system for the managing the drug supplies system

Intervention
6.2.2. Strengthen the existing MC and RDTs centers for treating the malaria cases
as per the national treatment guidelines and ensure treatment compliance

54
List of Activities:
6.2.2.1. Refresher training of doctors on treatment guidelines
6.2.2.2. Ensure that the doctors are prescribing the drugs as per the national
treatment guidelines by reducing the number of clinically diagnosed malaria
cases
6.2.2.3. Develop mechanism to ensure patient compliance to treatment (DOT)

Intervention
6.2.3. Involve LHWs in DOT in malaria and ACSM activities in high and moderate
malaria risk districts

List of Activities:
6.2.3.1. Train at least 50% LHWs in DOT and ACSM related to malaria
6.2.3.2. LHW for DOT where available and family member where no LHW
present or not involved)
6.2.3.3. Provide ACSM materials
6.2.3.4. Monitor progress of LHWs on DOT and ACSM

Strategy
6.3. Strengthen quality assurance system for diagnostic services at national,
provincial/regional and at district level

Intervention
6.3.1. Strengthen the current QA system at national and provincial/regional head quarter
reference laboratories

List of Activities:
6.3.1.1. Arrange staff for reference laboratories include; Incharge reference lab
i.e. Medical technologist supported by 2 microscopist
6.3.1.2. Arrange premises for QA reference laboratories
6.3.1.3. Arrange vehicle for field visits, 3 microscopes, 1 teaching microscope,
reagents, slides cabinets, reference slides, infection prevention practices (IPP),
waste disposal, etc) for each reference laboratory

55
 6.3.1.4. Establish system for QA arrangements at province/regional level at MC
and RDTs centers
6.3.1.5. Establish proper feedback system for the province/ regional MC and
RDTs center
Intervention
6.3.2. Strengthen the QA system at district/ agency level

List of Activities:
6.3.2.1. Assign focal person at district/ agency head quarter for QA of diagnostic
services
6.3.2.2. Train the focal person in QA
6.3.2.3. Arrange equipment and supplies for QA system
6.3.2.4. Arrange mobility support (motor cycle) for the focal person to manage
QA operations at facility level

Objective 2: Ensure and sustain 80% coverage of multiple prevention interventions (IRS, LLINs
& and other innovative tools and technologies under IVM framework) in the target population as
per national guidelines by 2020

Strategy
6.4. Universal coverage with LLINs in 66 districts with API/SPR > 5 (mass
distribution) and in foci and emergencies in 57 districts with API between 1-5
and API <1

Table 23: LLINs requirements for universal coverage (2015-2020)

2015 2016 2017 2018 2019 2020
No of LLINs No of LLINs No of LLINs No of LLINs No of LLINs No of LLINs
Stratum I Punjab 493,613 509,112 18,521 18,812 167,191 121,229
Sindh 2,648,847 3,438,496 332,567 235,057 923,701 818,772
KPK 2,100,980 2,992,329 351,255 236,749 742,597 712,531
Balochistan 1,557,100 2,143,666 235,889 161,406 547,582 510,448
FATA 424,489 875,004 160,225 99,167 160,186 208,355
Stratum II Punjab 79,832 82,339 2,995 3,042 27,040 19,606
Sindh 5,247 235,169 79,209 45,469 7,252 55,998
KPK - - - - - -

56
 Balochistan 6,167 6,360 231 235 2,089 1,515
FATA - - - - - -
Stratum III Punjab 576,693 594,801 21,638 21,978 195,331 141,634
Sindh 118,058 121,765 4,430 4,499 39,987 28,995
KPK 66,172 68,250 2,483 2,522 22,413 16,252
Balochistan - - - - - -
FATA - - - - - -
Total Punjab 1,150,137 1,186,252 43,154 43,832 389,561 282,470
Sindh 2,761,658 3,795,430 416,205 285,025 970,940 903,765
KPK 2,167,153 3,060,579 353,738 239,270 765,010 728,783
Balochistan 1,563,267 2,150,027 236,120 161,641 549,671 511,963
FATA 424,489 875,004 160,225 99,167 160,186 208,355
8,066,705 11,067,292 1,209,443 828,936 2,835,368 2,635,336

Intervention
6.4.1. Arrange LLINs for uncovered households in districts with API/SPR > 5 in stratum I
and foci in stratum II and III and for potential epidemics

List of Activities:
6.4.1.1. Calculation of LLINs requirement for the households in high risk areas
6.4.1.2. Calculation of LLINs for the moderate and low risk districts and
emergency response
6.4.1.3. Arrange LLINs as per the required number
6.4.1.4. Enhance storage capacity for LLINs at provincial/regional and district
level
6.4.1.4. Involve all the stakeholders in LLINs distribution
6.4.1.5. Implement LLINs distribution strategy ‘Mass distribution’ in stratum I
6.4.1.6. Distribute LLINs through ANC clinic in foci in stratum II and III
6.4.1.7. Calculation of LLINs replacement requirement for the already covered
house holds
6.4.1.8. Periodic replacement of already distributed LLINs in households

57
Strategy
6.5. Implement IRs in 66 high risk districts with API/SPR >5 (15% Household)
and selective spraying in foci and emergency supplies of IRS for 57 moderate
and low risk districts
Table 24: Households to be covered through IRS (2015-17)
2015 2016 2017 Total 6 yrs
No of HH No of HH No of HH No of HH
Stratum I Punjab 49,776 50,558 51,351 151,685
Sindh 379,561 341,461 346,822 1,067,844
KPK 292,561 297,154 301,820 891,535
Balochistan 209,587 212,878 216,220 638,684
FATA 66,538 86,893 88,257 241,688

;2Stratum II Punjab 9,089 8,177 8,305 25,571

Sindh 25,959 23,353 23,720 73,033
KPK - - - -
Balochistan 702 632 642 1,975
FATA - - - -

Stratum III Punjab 65,658 59,067 59,994 184,719

Sindh 13,441 12,092 12,282 37,815
KPK 7,534 6,778 6,884 21,195
Balochistan - - - -
FATA - - - -

Total Punjab 124,523 117,801 119,651 361,974

Sindh 418,962 376,906 382,824 1,178,692
KPK 300,095 303,932 308,704 912,730
Balochistan 210,289 213,509 216,861 640,659
FATA 66,538 86,893 88,257 241,688
1,120,407 1,099,041 1,116,296 3,335,744

58
Intervention
6.5.1. 15% UCs will be targeted through a single round of post monsoon IRS aiming at
100% spray coverage within the target UC. The coverage will be sustained for
consecutive 3 years to maintain the pressure for high impact.
2 rounds of IRS to be implemented where disease transmission is extended.

List of Activities:
6.5.1.1. Calculation of IRS requirement (using facility based data for hotspots) for
the households (15% of the lowest administrative units i.e. union councils
inhibited by 10-15,000 population are faced with seasonal P.falciparum
outbreaks)
6.5.1.2. Enhance storage capacity for IRS at district/ agency level
6.5.1.3. Arrange equipment for IRS and Map the areas to be sprayed
6.5.1.4. Formulate IRS teams at district/ agency (one month before the
transmission seasons)
6.5.1.5. Implement IRS i.e. 1 rounds per year in post monsoon in areas with short
disease transmission period and 2 rounds in areas with long disease
transmission
6.5.1.6. Sustain coverage for consecutive 3 years to maintain the pressure for
high impact.
6.5.1.7. Involve all the stakeholders in IRS implementation
6.5.1.8. Establish IRS supervisory system
6.5.1.9. Establish sentinel sites for vector resistance to insecticide
6.5.1.10. Monitor the resistance level of local vector species to all four classes of
insecticides
6.5.1.11. Follow the global plan for insecticide resistance management (GPIRM)
6.5.1.12. Conduct IRS resistance studies and decide the choice of insecticide
based on the results in 2015
6.5.1.11. Arrange human resource and train on monitoring vector resistance

Strategy

6.6. Implement LSM targeted to eliminate malaria foci in districts and to support
urban malaria control & elimination, and general nuisance mosquito control.

59
Intervention
6.6.1. Effective implementation of larvicidal (LSM) in selected areas

List of Activities:
6.6.1.1. Map the areas where larvicidal need to be implemented
6.6.1.2. Calculation of larvicidal requirement as per the sites
6.6.1.3. Enhance storage capacity for larvicidal at provincial/regional and district
level
6.6.1.4. Plan larvicidal implementation
6.6.1.5. Arrange larvicidal
6.6.1.6. Formulate larvicidal implementation teams at district/ agency level
6.6.1.7. Involve all the stakeholders in larvicidal implementation
6.6.1.8. Establish larvicidal supervisory system
6.6.1.9. Implement larvicidal in the selected locations
Intervention
6.6.2. Establish effective entomological surveillance

List of Activities:
6.6.2.1. Ensure availability of entomologist
6.6.2.2. Train entomologist
6.6.2.3. Ensure effective implementation of legislative measures for vector
control as part of IVM
6.6.2.4. Establish vector sentinel surveillance sites in different eco-
epidemiological settings with standard guidelines

Objective 3: Increase community awareness up to 80% on the benefits of early diagnosis and
prompt treatment and malaria prevention measures using health promotion, advocacy and BCC
intervention by 2020

Strategy
6.7. Comprehensive implementation of BCC interventions in all 66 high risk
districts

60
 Intervention
6.7.1. Develop and monitor BCC interventions as per the community needs and COMBI
approach

List of Activities:
6.7.1.1. Review the current BCC intervention in context of provinces/regions with
districts and agencies having API/SPR > 5
6.7.1.2. Refine current BCC strategy and materials
6.7.1.3. Develop message and materials in local context in-line with recent
behavior change theories
6.7.1.4. Pilot test the new model and materials for BCC interventions
6.7.1.5. Evaluate and scale-up the interventions

Intervention
6.7.2. Implement BCC interventions in all high risk districts/agencies

Table 25: Advocacy with CBO, NGO s and LHWs

2015 2016 2017 2018 2019 2020
No of No of No of No of No of No of Cost
Beneficiaries Beneficiaries Beneficiaries Beneficiaries Beneficiaries Beneficiaries
Stratum I Punjab 650 650 650 650 650 650 18,474
Sindh 8,930 8,930 8,930 8,930 8,930 8,930 253,800
KPK 7,190 7,190 7,190 7,190 7,190 7,190 204,347
Balochistan 13,450 13,450 13,450 13,450 13,450 13,450 382,263
FATA 8,790 8,790 8,790 8,790 8,790 8,790 249,821
Stratum II Punjab 870 870 870 870 870 870 24,726
Sindh 4,760 4,760 4,760 4,760 4,760 4,760 135,284
KPK - - - - - - -
Balochistan 630 630 630 630 630 630 17,905
FATA - - - - - - -
Stratum III Punjab 27,840 27,840 27,840 27,840 27,840 27,840 791,242
Sindh 1,810 1,810 1,810 1,810 1,810 1,810 51,442
KPK 6,960 6,960 6,960 6,960 6,960 6,960 197,811
Balochistan - - - - - - -
FATA - - - - - - -
Total Punjab 29,360 29,360 29,360 29,360 29,360 29,360 834,442

61
 Sindh 15,500 15,500 15,500 15,500 15,500 15,500 440,526
KPK 14,150 14,150 14,150 14,150 14,150 14,150 402,158
Balochistan 14,080 14,080 14,080 14,080 14,080 14,080 400,168
FATA 8,790 8,790 8,790 8,790 8,790 8,790 249,821

81,880 81,880 81,880 81,880 81,880 81,880 2,327,116

Table 26: Community awareness sessions at facility level 2015-2020

2015 2016 2017 2018 2019 2020
No of No of No of No of No of No of
Beneficiaries Beneficiaries Beneficiaries Beneficiaries Beneficiaries Beneficiaries
Stratum I Punjab 240 240 240 240 240 240
Sindh 2,880 2,880 2,880 2,880 2,880 2,880
KPK 3,360 3,360 3,360 3,360 3,360 3,360
Balochistan 6,960 6,960 6,960 6,960 6,960 6,960
FATA 2,400 2,400 2,400 2,400 2,400 2,400
Stratum II Punjab 240 240 240 240 240 240
Sindh 1,920 1,920 1,920 1,920 1,920 1,920
KPK - - - - - -
Balochistan 240 240 240 240 240 240
FATA - - - - - -
Stratum III Punjab 8,160 8,160 8,160 8,160 8,160 8,160
Sindh 720 720 720 720 720 720
KPK 2,400 2,400 2,400 2,400 2,400 2,400
Balochistan - - - - - -
FATA - - - - - -
Total Punjab 8,640 8,640 8,640 8,640 8,640 8,640
Sindh 5,520 5,520 5,520 5,520 5,520 5,520
KPK 5,760 5,760 5,760 5,760 5,760 5,760
Balochistan 7,200 7,200 7,200 7,200 7,200 7,200
FATA 2,400 2,400 2,400 2,400 2,400 2,400
29,520 29,520 29,520 29,520 29,520 29,520

Table 27: Community awareness session CBOs/NGOs (2015-2020

2015 2016 2017 2018 2019 2020
No of No of No of No of No of No of
Beneficiaries Beneficiaries Beneficiaries Beneficiaries Beneficiaries Beneficiaries

62
Stratum I Punjab 39,000 39,000 39,000 39,000 39,000 39,000
Sindh 535,800 535,800 535,800 535,800 535,800 535,800
KPK 431,400 431,400 431,400 431,400 431,400 431,400
Balochistan 807,000 807,000 807,000 807,000 807,000 807,000
FATA 527,400 527,400 527,400 527,400 527,400 527,400

Stratum II Punjab 52,200 52,200 52,200 52,200 52,200 52,200

Sindh 285,600 285,600 285,600 285,600 285,600 285,600
KPK - - - - - -
Balochistan 37,800 37,800 37,800 37,800 37,800 37,800
FATA - - - - - -

Stratum III Punjab 1,670,400 1,670,400 1,670,400 1,670,400 1,670,400 1,670,400

Sindh 108,600 108,600 108,600 108,600 108,600 108,600
KPK 417,600 417,600 417,600 417,600 417,600 417,600
Balochistan - - - - - -
FATA - - - - - -

Total Punjab 1,761,600 1,761,600 1,761,600 1,761,600 1,761,600 1,761,600

Sindh 930,000 930,000 930,000 930,000 930,000 930,000
KPK 849,000 849,000 849,000 849,000 849,000 849,000
Balochistan 844,800 844,800 844,800 844,800 844,800 844,800
FATA 527,400 527,400 527,400 527,400 527,400 527,400

4,912,800 4,912,800 4,912,800 4,912,800 4,912,800 4,912,800

Table 28: BCC by facility staff (2015-2020)

2015 2016 2017 2018 2019 2020
No of No of No of No of No of No of
Beneficiaries Beneficiaries Beneficiaries Beneficiaries Beneficiaries Beneficiaries
Stratum I Punjab 325 325 325 325 325 325
Sindh 4,465 4,465 4,465 4,465 4,465 4,465
KPK 3,595 3,595 3,595 3,595 3,595 3,595
Balochistan 6,725 6,725 6,725 6,725 6,725 6,725
FATA 4,395 4,395 4,395 4,395 4,395 4,395

Stratum II Punjab 435 435 435 435 435 435

Sindh 2,380 2,380 2,380 2,380 2,380 2,380

63
 KPK - - - - - -
Balochistan 315 315 315 315 315 315
FATA - - - - - -

Stratum III Punjab 13,920 13,920 13,920 13,920 13,920 13,920

Sindh 905 905 905 905 905 905
KPK 3,480 3,480 3,480 3,480 3,480 3,480
Balochistan - - - - - -
FATA - - - - - -

Total Punjab 14,680 14,680 14,680 14,680 14,680 14,680

Sindh 7,750 7,750 7,750 7,750 7,750 7,750
KPK 7,075 7,075 7,075 7,075 7,075 7,075
Balochistan 7,040 7,040 7,040 7,040 7,040 7,040
FATA 4,395 4,395 4,395 4,395 4,395 4,395

40,940 40,940 40,940 40,940 40,940 40,940

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Table 29: BCC- Street Theater
2015 2016 2017 2018 2019 2020
No of No of No of No of No of No of
Events Events Events Events Events Events
Stratum I Punjab 65 - 65 - 65 -
Sindh 893 - 893 - 893 -
KPK 719 - 719 - 719 -
Balochistan 1,345 - 1,345 - 1,345 -
FATA 879 - 879 - 879 -

Stratum II Punjab 87 - 87 - 87 -
Sindh 476 - 476 - 476 -
KPK - - - - - -
Balochistan 63 - 63 - 63 -
FATA - - - - - -

Stratum III Punjab 2,784 - 2,784 - 2,784 -

Sindh 181 - 181 - 181 -
KPK 696 - 696 - 696 -
Balochistan - - - - - -
FATA - - - - - -

Total Punjab 2,936 - 2,936 - 2,936 -

Sindh 1,550 - 1,550 - 1,550 -
KPK 1,415 - 1,415 - 1,415 -
Balochistan 1,408 - 1,408 - 1,408 -
FATA 879 - 879 - 879 -

8,188 - 8,188 - 8,188 -

Table 30: World Malaria day events (2015-2020)

2015 2016 2017 2018 2019 2020
No of No of No of No of No of No of
Events Events Events Events Events Events
Stratum I Punjab
1 1 1 1 1 1
Sindh
12 12 12 12 12 12
KPK
14 14 14 14 14 14
Balochistan
29 29 29 29 29 29
FATA
10 10 10 10 10 10

65
 Stratum II Punjab
1 1 1 1 1 1
Sindh
8 8 8 8 8 8
KPK
- - - - - -
Balochistan
1 1 1 1 1 1
FATA
- - - - - -

Stratum III Punjab

34 34 34 34 34 34
Sindh
3 3 3 3 3 3
KPK
10 10 10 10 10 10
Balochistan
- - - - - -
FATA
- - - - - -

Total Punjab
36 36 36 36 36 36
Sindh
23 23 23 23 23 23
KPK
24 24 24 24 24 24
Balochistan
30 30 30 30 30 30
FATA
10 10 10 10 10 10

123 123 123 123 123 123

Table 31: BCC- Branding of facilities

2015 2016 2017 2018 2019 2020
No of No of No of No of No of No of
Beneficiaries Beneficiaries Beneficiaries Beneficiaries Beneficiaries Beneficiaries
Stratum I Punjab 65 - 65 -
65 -
Sindh 893 - 893 -
893 -
KPK 719 - 719 -
719 -
Balochistan 1,345 - 1,345 -
1,345 -
FATA 879 - 879 -
879 -

66
Stratum II Punjab 87 - 87 -
87 -
Sindh 476 - 476 -
476 -
KPK - - - -
- -
Balochistan 63 - 63 -
63 -
FATA - - - -
- -

Stratum III Punjab 2,784 - 2,784 -

2,784 -
Sindh 181 - 181 -
181 -
KPK 696 - 696 -
696 -
Balochistan - - - -
- -
FATA - - - -
- -

Total Punjab 2,936 - 2,936 -

2,936 -
Sindh 1,550 - 1,550 -
1,550 -
KPK 1,415 - 1,415 -
1,415 -
Balochistan 1,408 - 1,408 -
1,408 -
FATA 879 - 879 -
879 -

8,188 - 8,188 -
8,188 -

Table 32: BCC- Broadcast radio message (2015-2020)

2015 2016 2017 2018 2019 2020
No of No of No of No of No of No of
Beneficiaries Beneficiaries Beneficiaries Beneficiaries Beneficiaries Beneficiaries
Stratum I Punjab 1,460 1,460 730 730 365 365
Sindh 17,520 17,520 8,760 8,760 4,380 4,380
KPK 20,440 20,440 10,220 10,220 5,110 5,110
Balochistan 42,340 42,340 21,170 21,170 10,585 10,585
FATA 14,600 14,600 7,300 7,300 3,650 3,650

Stratum II Punjab 730 730 730 730 365 365

Sindh 5,840 5,840 5,840 5,840 2,920 2,920
KPK - - - - - -

67
 Balochistan 730 730 730 730 365 365
FATA - - - - - -

Stratum III Punjab 12,410 12,410 12,410 12,410 - -

Sindh 1,095 1,095 1,095 1,095 - -
KPK 3,650 3,650 3,650 3,650 - -
Balochistan - - - - - -
FATA - - - - - -

Total Punjab 14,600 14,600 13,870 13,870 730 730

Sindh 24,455 24,455 15,695 15,695 7,300 7,300
KPK 24,090 24,090 13,870 13,870 5,110 5,110
Balochistan 43,070 43,070 21,900 21,900 10,950 10,950
FATA 14,600 14,600 7,300 7,300 3,650 3,650

120,815 120,815 72,635 72,635 27,740 27,740

List of Activities:
6.7.2.1. Implement focused BCC intervention for suspected malaria cases
through interpersonal communication
6.7.2.2. Involve electronic and print media in advocacy
6.7.2.3. Community events in mobilizing households to use LLINs and access
health facilities in case of fever
6.7.2.4. Provincial/Regional and district level events: high-level discussions
around malaria
6.7.2.5. Field visits for high-level officials or journalists
6.7.2.6. Production of IEC materials to improve knowledge of malaria and
prevention in the general population
6.7.2.7. Mass media campaigns involving electronic and print media: Broadcast
materials (Public Service Announcement)
6.7.2.8. Training of care providers in using IEC materials to educate patients
6.7.2.9. Training of LHWs and volunteers: Community involvement

68
Objective 4: Enhance technical and managerial capacity in planning, implementation,
management and MEAL (Monitoring, Evaluation, Accountability and Learning) of malaria
prevention and control intervention by 2016

Strategy
6.8. Increase public sector funding for malaria control interventions
Intervention
6.8.1. Revise PC-1s all provinces and regions to secure funding from 2015 and onward

List of Activities:
6.8.1.1. Develop PC-1 to sustain and expand malaria control and prevention
activities
6.8.1.2. Advocacy with key stakeholders to sensitize for the approval and release
of PC-1 funds
6.8.1.3. Effective implementation of operational plan through PC-1 support

Intervention
6.8.2. Enhance contribution of district/ agency health authorities in malaria control
activities in their respective areas

List of Activities:
6.8.2.1. Secure adequate funding support from the total budgetary allocation for
procurement of laboratory supplies such as slides, reagents and chemicals, IRS,
and anti-malarial drugs
6.8.2.2. Adequate support for the district/agency malaria control team
(DoH/DDoH/Malaria Superintendent, Microscopist, etc) for monitoring and quality
control activities

Intervention
6.8.3. Increase donor commitments to address comprehensively malaria control needs
in provinces/ regions

69
List of Activities:
6.8.3.1. Coordinate with international technical and donor agencies such as
WHO, Global Fund, USAID, DFID, etc (IACC)
6.8.3.2. Increase international technical and donor assistance to meet the
financial gaps for malaria control and prevention activities

Strategy
6.9. Strengthen national and provincial/regional and district set-up with
technical and administrative human resource
Intervention
6.9.1. Arrange adequate technical and administrative human resource at national and
provincial/ regional malaria control program and at district/ agency level to address malaria
control interventions

List of Activities:
6.9.1.1. Recruitment of technical and administrative staff at national and
provincial/regional and district and agency level to carry out M&E, QA,
Surveillance, Malaria Prevention and Management functions , etc
6.9.1.2. Train human resource to carry out surveillance activities
6.9.1.3. Train human resource to carry out financial management
6.9.1.4. Train human resource to plan, store and implement effectively LLINs and
IRS in the targeted areas

Intervention
6.9.2. Implement effective M&E system at national, provincial/regional and district level
6.9.2.1. Arrange technical human resource and logistics to carry out M&E
functions
6.9.2.2. Train human resource to carry out M&E functions
6.9.2.3. Standardize the reporting of core malaria indictors to avoid
variation with DHIS/DEWS
6.9.2.4. Collect and manage on malaria inpatients and mortality from
hospital (secondary and tertiary) DHIS reporting.

70
 6.9.2.5. Establish GIS and malaria mapping capacity within the region to
guide malaria epidemiological analysis and target interventions at districts
level.
6.9.2.6. Establishing Sentinel Surveillance Sites (SSS) at districts and
prominent hospitals to monitor the trends of disease morbidity and
mortality;
6.9.2.7. Implement periodic population and facility based surveys
Intervention
6.9.3. Establish coordinating committee and ensure their effectiveness

List of Activities:
6.9.3.1. Establish and operationalize Technical Advisory Committee on malaria
(TACOM)
6.9.3.2. Establish and operationalize regional coordinating committee
6.9.3.3. Establish and operationalize inter-sectoral coordination committee
(department of education, agriculture, information, local bodies, etc)

Strategy
6.10. Operational research to inform policy and decision making
Intervention
6.10.1. Enhance capacity to carry out operational research

List of Activities:
6.10.1.1. Develop and implement operational research projects
6.10.1.2. Establish partnerships with research academic at provincial/ regional
level and in Islamabad
6.10.1.3. National Malaria Prevalence Survey
6.10.1.4. Insecticide Resistant Survey
6.10.1.5. Drug Resistant Survey
6.10.1.6. Operational research on treatment compliance and efficacy
6.10.1.7. Operational research on malaria case management in private sector

71
Strategy
6.11. Procurement and good storage practices at national and
provincial/regional and district for anti-malarial drugs, LLINs and IRS

Intervention
6.11.1. Enhance capacity of provincial/regional and district stores to follow good practice
standards for the storage of anti-malarial drugs, LLINs and IRS

List of Activities:
6.11.1.1. Anti-malarial drugs, LLINs and IRS procurement
6.11.1.2. Refurbish provincial/regional and district stores to implement good
practice for the storage of anti-malarial, LLINs and IRS
6.11.1.3. Training of provincial/regional and district coordinators on drugs, LLINs
and IRS management
6.11.1.4. Implement the logistics management information system

Strategy
6.12. Establish core of master trainers at provincial/regional level
Intervention
6.12.1. Enhance capacity of provincial/regional level to implement quality trainings
List of Activities:
6.12.1.1. Develop a core of master trainers on malaria case management, LLINs,
IRS, M&E and surveillance
6.12.1.2. Develop training plans based on the local needs
6.12.1.3. Arrange resources i.e. materials, etc to carry out trainings

72
Objective 5: Ensure availability of quality assured strategic information (epidemiological,
entomological and operational) for informed decision making

Strategy
6.13. Standardized recording and reporting system for malaria case management
and prevention and entomological information

Intervention
6.13.1. Implement MIS for malaria at MC and RDT centers

List of Activities:
6.13.1.1. Provide standardize MIS recording and reporting forms and registers at
all malaria diagnostic MC and RDTs centers in districts/ agencies and facility
level
6.13.1.2. Establish mechanism for regular collection of data from the facilities by
establish entomological surveillance sites
6.13.1.3. Establish system for timely and quality assured data collection
6.13.1.4. Implement data collection system for vector bionomics, information on
breeding, biting and resting habits and other vector related information from the
targeted sites in the districts/agencies
6.13.1.5. Establish system at provincial/regional level to review data on regular
basis and make decision accordingly
6.13.1.6. Establish a regular system of third party review of the program activities
6.13.1.7. Establish entomological surveillance sites
6.13.1.8. Establish sentinel sites
6.13.1.9. Design and implement longitudinal studies

73
Objective 6: Ensure provision of malaria prevention, treatment and control services in
humanitarian crises, emergencies and cross-border situation

Strategy
6.14. Capacity at provincial/regional and district level to address malaria control
and prevention in humanitarian crises, emergencies and cross-border
situation
Intervention
6.14.1. Establish provincial/ regional and district/agency capacity to address emergency
situation including epidemics and cross-border situation

List of Activities:
6.14.1.1. Prepare capacity development plan including roles and responsibilities
at provincial/regional and district/agency level to address emergency situations
and malaria in cross-border situation
6.14.1.2. Strengthening and scale-up of early warning system for detection of
potential epidemics (DEWS, DHIS, etc)
6.14.1.3. Development and strengthening of rapid response teams to address
malaria epidemic in agencies
6.14.1.4. Arrange materials and supplies as a buffer stock to address
emergencies
6.14.1.5. Establish system to ensure timely response to emergencies and
epidemics
6.14.1.6. Establish linkages with various organizations at district level to address
emergencies

Intervention

6.14.2. Establish provincial/regional and district capacity to address cross-border

situation and movement of nomadic population
Activities
6.14.2.1. For nomadic population, provide services through static centers and
mobile units

74
6.14.2.2. Strengthen border health posts to manage uncomplicated and
complicated malaria
6.14.2.3. Arrange and conduct cross border coordination including exchange
visits, policy dialogue, joint interventions, etc

75
 B-BUDGET SUMMARY

Note: The budget break ups are available in respective provincial and regional strategic plans.

76
BUDGET: YEARLY BREAK-UP

77
C- M&E FRAMEWORK

78
79
80